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End of life in patients attended by pediatric palliative care teams: what factors influence the place of death and compliance with family preferences? Eur J Pediatr 2023; 182:2369-2377. [PMID: 36890334 PMCID: PMC10175312 DOI: 10.1007/s00431-023-04870-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/05/2023] [Accepted: 02/08/2023] [Indexed: 03/10/2023]
Abstract
Each year, more than 8 million children worldwide require specialized palliative care, yet there is little evidence available in pediatrics on the characteristics of the end of life in this context. Our aim is to analyze the characteristics of patients who die in the care of specific pediatric palliative care teams. This is ambispective, analytical observational, multicenter study conducted between 1 January and 31 December 2019. Fourteen specific pediatric palliative care teams participated. There are 164 patients, most of them suffering from oncologic, neurologic, and neuromuscular processes. The follow-up time was 2.4 months. The parents voiced preferences in respect of the place of death for 125 of the patients (76.2%). The place of death for 95 patients (57.9%) was at the hospital and 67 (40.9%) was at home. The existence of a palliative care team for over 5 years is more likely to be related to families voicing preferences and their fulfillment. Longer follow-up times by pediatric palliative care teams were observed in families with whom preferences regarding the place of death were discussed and in patients who died at home. Patients who did not receive home visits, when the pediatric palliative care team did not provide full care and when preferences regarding the place of death were not discussed with parents, were more likely to die in the hospital. Conclusions: Advance planning of end-of-life care is one of the most important aspects of pediatric palliative care. The provision of services by the teams and the follow-up time are related to parents' expressed preferences and the place of death. What is Known: • Various studies have shown how the availability of pediatric palliative care services improves the quality of life of patients and their families while reducing costs. • The place of death is an important factor influencing the quality of end-of-life care for dying people. The increase in palliative care teams increases the number of deaths in the home and having this care available 24/7 increases the probability of dying at home. What is New: • Our study identifies how a longer follow-up time of patients by palliative care teams is significantly associated with death at home and with express and comply with the preferences expressed by families. • Home visits by the palliative care team increase the likelihood that the patient will die at her home and that the preferences expressed by the palliative care team families will be cared for.
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Sadler K, Nancarrow L, Alyami HH, Abudari G. Implementing a nurse-led paediatric palliative care service. Int J Palliat Nurs 2022; 28:60-70. [PMID: 35446670 DOI: 10.12968/ijpn.2022.28.2.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Children with life-limiting illnesses are living longer. They have complex care needs and require specialised knowledge and skills, yet paediatric palliative care is still at its infancy in most settings worldwide. AIMS To describe the process of implementing a nurse-led paediatric palliative care programme in a large tertiary hospital in Saudi Arabia. METHODS The steps that led to the implementation of this new nurse-led programme will be described through a 1-year analysis of collected data. FINDINGS A total of 107 children received services from the paediatric palliative care programme for over one year, with cancer being the predominant diagnosis (n=71, 66.3%). More than half of the children had a do not attempt resuscitation (DNAR) order (n=54, 50.5%). The most frequently encountered issues were the family's difficulty in coping with the disease (n=80, 74.7%) and a child's uncontrolled pain (n=72, 67.3%). The most frequent interventions were family support and counselling (n=71, 66.3%), family education about symptom management (n=69, 64,5%) and adjusted analgesics (n=60, 56%). Children in the terminal stage of their disease had significantly more issues. CONCLUSION Effective paediatric palliative care can be successfully implemented in a healthcare setting even when resources are limited. A nurse-led service was found to be a viable option for the delivery of palliative care to children with serious illnesses.
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Affiliation(s)
- Kim Sadler
- Advanced Clinical Specialist Nurse, Palliative Care, King Faisal Specialist Hospital and Research Center, Riyadh
| | - Lori Nancarrow
- Advanced Clinical Specialist Nurse in Paediatrics, Princess Elizabeth Hospital, Guernsey, UK; King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hamad Husain Alyami
- Clinical Specialist Nurse in Paedatric Palliative Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Gassan Abudari
- Clinical Nurse Specialist in Palliative Care; King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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3
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Szymczak JE, Schall T, Hill DL, Walter JK, Parikh S, DiDomenico C, Feudtner C. Pediatric Oncology Providers' Perceptions of a Palliative Care Service: The Influence of Emotional Esteem and Emotional Labor. J Pain Symptom Manage 2018; 55:1260-1268. [PMID: 29425881 PMCID: PMC5908218 DOI: 10.1016/j.jpainsymman.2018.01.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 11/30/2022]
Abstract
CONTEXT Pediatric palliative care consults for children with cancer often occur late in the course of disease and close to death, when earlier involvement would reduce suffering. The perceptions that pediatric oncology providers hold about the pediatric palliative care service (PPCS) may shape referral patterns. OBJECTIVES To explore how pediatric oncology providers at one institution perceived the hospital's PPCS and the way these perceptions may influence the timing of consultation. METHODS We conducted semistructured qualitative interviews with pediatric oncology providers at a large children's hospital. Interviews were audio-recorded, transcribed, and analyzed by two coders using a modified grounded theory approach. RESULTS We interviewed 16 providers (10 physicians, one nurse practitioner, two social workers, two psychologists, and one child life specialist). Three core perceptions emerged: 1) the PPCS offers a diverse range of valuable contributions to the care of children with advancing cancer; 2) providers held favorable opinions about the PPCS owing to positive interactions with individual palliative care specialists deemed extraordinarily emotionally skilled; and 3) there is considerable emotional labor involved in calling a PPCS consult that serves as a barrier to early initiation. CONCLUSION The pediatric oncology providers in our study held a highly favorable opinion about their institution's PPCS and agreed that early consultation is ideal. However, they also described that formally consulting PPCS is extremely difficult because of what the PPCS symbolizes to families and the emotional labor that the provider must manage in introducing them. Interventions to encourage the early initiation of palliative care in this population may benefit from a focus on the emotional experiences of providers.
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Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Theodore Schall
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Douglas L Hill
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer K Walter
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Concetta DiDomenico
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Verberne LM, Kars MC, Schepers SA, Schouten-van Meeteren AYN, Grootenhuis MA, van Delden JJM. Barriers and facilitators to the implementation of a paediatric palliative care team. BMC Palliat Care 2018; 17:23. [PMID: 29433576 PMCID: PMC5810030 DOI: 10.1186/s12904-018-0274-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/22/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Over the last decade, paediatric palliative care teams (PPCTs) have been introduced to support children with life-limiting diseases and their families and to ensure continuity, coordination and quality of paediatric palliative care (PPC). However, implementing a PPCT into an organisation is a challenge. The objective of this study was to identify barriers and facilitators reported by healthcare professionals (HCPs) in primary, secondary or tertiary care for implementing a newly initiated multidisciplinary PPCT to bridge the gap between hospital and home. METHODS The Measurement Instrument for Determinants of Innovations (MIDI) was used to assess responses of 71 HCPs providing PPC to one or more of the 129 children included in a pilot study of a PPCT based at a university children's hospital. The MIDI (29 items) assessed barriers and facilitators to implementing the PPCT by using a 5-point scale (completely disagree to completely agree) and additional open-ended questions. Items to which ≥20% of participants responded with 'totally disagree/disagree' and ≥80% responded with 'agree/totally agree' were considered as barriers and facilitators, respectively. A general inductive approach was used for open-ended questions. RESULTS Reported barriers to implementing a PPCT were related to the HCP's own organisation (e.g., no working arrangements related to use of the intervention [PPCT] registered, other organisational changes such as merger going on). Reported facilitators were mainly related to the intervention (correctness, simplicity, observability and relevancy) and the user scale (positive outcome expectations, patient satisfaction) and only once to the organisation scale (information accessibility). Additionally, HCPs expressed the need for clarity about tasks of the PPCT and reported having made a transition from feeling threatened by the PPCT to satisfaction about the PPCT. CONCLUSION Positive experiences with the PPCT are a major facilitator for implementing a PPCT. Tailored organisational strategies such as working arrangements by management, concrete information about the PPCT itself and the type of support provided by the PPCT should be clearly communicated to involved HCPs to increase awareness about benefits of the PPCT and ensure a successful implementation. New PPCTs need protection and resources in their initial year to develop into experienced and qualified PPCTs.
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Affiliation(s)
- Lisa M. Verberne
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO BOX 85500, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Marijke C. Kars
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO BOX 85500, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Sasja A. Schepers
- Psychosocial Department, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Lundlaan 6, 3584 AE Utrecht, The Netherlands
- Department of Psychology, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105 USA
| | | | - Martha A. Grootenhuis
- Psychosocial Department, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Lundlaan 6, 3584 AE Utrecht, The Netherlands
| | - Johannes J. M. van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO BOX 85500, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
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5
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Liberman DB, Song E, Radbill LM, Pham PK, Derrington SF. Early introduction of palliative care and advanced care planning for children with complex chronic medical conditions: a pilot study. Child Care Health Dev 2016; 42:439-49. [PMID: 27028099 DOI: 10.1111/cch.12332] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 01/25/2016] [Accepted: 02/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children with complex chronic medical conditions benefit from early introduction of palliative care services and advanced care planning for symptom management and to support quality of life and medical decision-making. This study evaluated whether introducing palliative care during primary care appointments (1) was feasible; (2) increased access and improved knowledge of palliative care; and (3) facilitated advanced care planning. METHODS Pilot study of a multi-modal intervention including targeted education for primary care providers (PCPs), an informational packet for families and presence of a palliative care team member in the outpatient clinic. PCPs completed pre- and post-surveys assessing experience, knowledge and comfort with palliative care. Enrolled families received an information packet; a subset also met a palliative care team member. All families were encouraged to make an appointment with the palliative care team, during which the team assessed palliative care needs and goals of care. Upon study completion, the investigators assessed family and PCP satisfaction and collected feedback on project feasibility. RESULTS Twenty families were enrolled and received the information packet; 15 met a palliative care team member. Of the 17 participating families who were reached and completed a post-study survey, 11 families had never heard of palliative care and 13 were unaware that the palliative care team existed. Most families perceived palliative care information as 'very helpful' and 'very important'. All would recommend palliative care team services to others. Nine families followed up with the palliative care team, but none was prepared to complete an advanced care plan. PCPs reported lack of training in communicating bad news and conducting goals of care discussions. However, they felt increasingly comfortable introducing palliative care to families and supported program continuation. CONCLUSIONS Initiating palliative care services in the outpatient primary care setting is logistically challenging but increases access to palliative care for children with complex chronic medical conditions and improves palliative care knowledge and comfort for PCPs.
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Affiliation(s)
- D B Liberman
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - E Song
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - L M Radbill
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.,Division of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - P K Pham
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - S F Derrington
- Division of Critical Care and Program in Palliative Care, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Abstract
Pediatric medicine increasingly has recognized the value of integrating behavioral health in medical care, but this trend has not yet extended to pediatric palliative care. Results from a recent survey of pediatric palliative care programs across the United States indicate that team composition almost never included a psychologist. This article presents a model of collaborative care to optimize the integration of psychosocial and medical aspects of treatment in pediatric palliative care, delineating how a psychologist adds to this model. This article argues that psychology brings specialized skills in assessment, intervention, and research that fit with the premise of palliative care as a holistic approach that relieves symptoms. Systematic inclusion of psychologists on pediatric palliative care teams may help to improve effectiveness of services as well as extend the knowledge base of mental health in pediatric palliative care.
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Affiliation(s)
- Emily Edlynn
- 1 Pediatric Mental Health Institute, University of Colorado School of Medicine , Denver, Colorado
- 2 Pediatric Mental Health Institute, Children's Hospital Colorado , Aurora, Colorado
| | - Harpreet Kaur
- 3 Department of Child Health, Phoenix Children's Hospital , Phoenix, Arizona
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Keele L, Keenan HT, Bratton SL. The Effect of Palliative Care Team Design on Referrals to Pediatric Palliative Care. J Palliat Med 2015; 19:286-91. [PMID: 26670933 DOI: 10.1089/jpm.2015.0261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The American Academy of Pediatrics (AAP) and the American Academy of Hospice and Palliative Medicine (AAHPM) have recommended minimal standards for palliative care (PC) team composition and availability. It is unknown whether team composition affects utilization of PC. OBJECTIVE The study objective was to describe pediatric PC team composition, evaluate whether composition and availability are associated with utilization, and examine PC referral patterns. METHODS The study was a descriptive survey. Subjects were pediatric PC team directors or hospital administrators at Pediatric Health Information System (PHIS) hospitals (N = 44). RESULTS The overall response rate was 86%. Teams varied in size from <1 to 9 full-time members. Average referrals per hospital bed were 0.46, range 0.05-2.13. Among individual PC team roles, referral rates were 34% greater in teams with an advanced nurse practitioner (ANP) (p = 0.07). Likewise, teams with acute pain, chronic pain, or hospice palliative medicine specialists tended to have greater referral rates (39%, 36%, and 25%), though reported differences were not statistically significant. Teams adherent to the original AAP recommendations had a 31% greater referral rate (p = 0.22). Teams available 24 hours daily had similar referral rates to those with less availability (0.47 versus 0.46 [p = 0.94]). CONCLUSIONS Team composition and availability are not crucial to PC utilization. Hospitals with some personnel but not all recommended team members should create formal teams and modify them over time. The addition of team members that tend to increase referrals, namely ANPs and acute pain, chronic pain, or hospice palliative medicine specialists, should be considered.
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Affiliation(s)
- Linda Keele
- 1 Department of Anesthesia and Critical Care, Valley Children's Hospital , Fresno, California
| | - Heather T Keenan
- 2 Department of Pediatrics, Division of Critical Care, University of Utah , Salt Lake City, Utah
| | - Susan L Bratton
- 2 Department of Pediatrics, Division of Critical Care, University of Utah , Salt Lake City, Utah
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8
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Supportive and palliative care of children with metabolic and neurological diseases. Curr Opin Support Palliat Care 2015; 8:296-302. [PMID: 25004174 DOI: 10.1097/spc.0000000000000063] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review the role of pediatric palliative care (PPC) for children with metabolic and neurological diseases. RECENT FINDINGS There is a growing body of literature in PPC, though it remains limited for children with metabolic and neurological diseases. Evidence indicates the benefit of PPC. Utilization of PPC programmes can facilitate communication, ensure that families are better informed, improve certainty with decisions, enhance positive emotions, result in fewer invasive interventions at the end of life, and have an impact on location of death. Barriers to utilization of PPC include concern about taking away hope and uncertainty about prognosis. Challenging areas for children with metabolic and neurological diseases include the identification of distressing symptoms and prognostic uncertainty. This article aims to review literature relevant to this group of children, as well as provide a framework when considering specific palliative care needs. SUMMARY PPC for children with metabolic and neurological diseases can lessen a child's physical discomfort and enhance parental certainty with decision-making. These areas along with other needs throughout the illness trajectory and bereavement are being increasingly met by the growing availability of PPC programmes.
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Miller EG, Frizzola MA, Levy C, Greenspan JS. Recent experience establishing a new pediatric palliative care team. J Pediatr 2015; 166:4-5. [PMID: 25527850 DOI: 10.1016/j.jpeds.2014.09.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Elissa G Miller
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
| | - Meg A Frizzola
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Carly Levy
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Jay S Greenspan
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
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Frizzola M, Miller EG. Referrals to a new pediatric palliative care team: details of the first 12 months of operation. J Palliat Med 2014; 17:585-8. [PMID: 24576099 DOI: 10.1089/jpm.2013.0206] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although the field of pediatric palliative care (PPC) remains in its infancy, over the past decade it has grown in practice and scope. We report on patient referral patterns to a new PPC team at a free-standing children's hospital. OBJECTIVE Our aim is to provide a descriptive comparison of the patient population seen by our new program as compared to existing literature. METHODS We examined our database of patient referral and demographic data and compared our data with published reports. CONCLUSIONS Our team was operating beyond its predicted year-one volume with a patient population that mirrored larger, more established programs. In an era of growth and acceptance of PPC, hospitals that have undergone a strong needs assessment, significant educational effort, and have a strong prediction of patient volume should expect to be operating at projected capacity quickly.
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Affiliation(s)
- Meg Frizzola
- 1 Department of Anesthesia and Critical Care Medicine, Nemours/Alfred I. duPont Hospital for Children , Wilmington, Delaware
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Feudtner C, Womer J, Augustin R, Remke S, Wolfe J, Friebert S, Weissman D. Pediatric palliative care programs in children's hospitals: a cross-sectional national survey. Pediatrics 2013; 132:1063-70. [PMID: 24190689 DOI: 10.1542/peds.2013-1286] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric palliative care (PPC) programs facilitate the provision of comprehensive care to seriously ill children. Over the past 10 years many such programs have been initiated by children's hospitals, but little is known about their number, staff composition, services offered, sources of support, or national distribution. METHODS In the summer of 2012, we surveyed 226 hospitals as identified by the National Association of Children's Hospitals and Related Institutions. The survey instrument gathered data about whether their institution had a PPC program, and for hospitals with programs, it asked for a wide range of information including staffing, patient age range, services provided, and financial support. RESULTS Of the 162 hospitals that provided data (71.7% response rate), 69% reported having a PPC program. The rate of new program creation peaked in 2008, with 12 new programs created that year, and 10 new programs in 2011. Most programs offer only inpatient services, and most only during the work week. The number of consults per year varied substantially across programs, and was positively associated with hospital bed size and number of funded staff members. PPC programs report a high level of dependence on hospital funding. CONCLUSIONS PPC programs are becoming common in children's hospitals throughout the United States yet with marked variation in how these programs are staffed, the level of funding for staff effort to provide PPC, and the number of consultations performed annually. Guidelines for PPC team composition, funding, and consultation standards may be warranted to ensure the highest quality of PPC.
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Affiliation(s)
- Chris Feudtner
- CHOP North, Room 1523, The Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 10194.
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