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Cuviello A, Pasli M, Bhatia S, Johnson LM, Anghelescu DL, Baker JN. Dexmedetomidine and Propofol at End of Life in Pediatric Oncology: Trends in Palliative Sedation Therapy. J Palliat Med 2023; 26:79-86. [PMID: 35944277 PMCID: PMC9810498 DOI: 10.1089/jpm.2021.0650] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 01/13/2023] Open
Abstract
Context: Palliative sedation therapy (PST) can address suffering at the end of life (EOL) in children with cancer; yet, little is known about PST in this population. Objectives: We sought to describe the characteristics of pediatric oncology patients requiring PST at the EOL. Methods: A retrospective review was completed for pediatric oncology patients who required PST at a United States academic institution over 10 years, including demographics, disease characteristics, EOL characteristics, and medications for PST and symptom management. Results: PST was utilized in 3% of patients at the EOL. Of 24 study participants receiving PST, 83% (n = 20), 12.5% (n = 3), and 4.2% (n = 1) received dexmedetomidine, propofol, or both, respectively. The most frequent diagnosis for patients receiving PST was acute myelogenous leukemia (20.8%, n = 5). All patients were followed up by the palliative care team, and two-thirds (66.6%, n = 16) were also followed up by the pain management service; 79% (n = 19) were enrolled in hospice, and 98.5% (n = 23) had a Physician Orders for Scope of Treatment in place. Pain was the most common refractory symptom leading to PST initiation (33.3%, n = 8), followed by neuroagitation and dyspnea. PST was initiated a median of 2.5 days before death. A third of deaths occurred in the intensive care unit (33.3%, n = 8). Conclusions: PST was rare in this study; dexmedetomidine was used as first-line treatment for PST in patients at the EOL with refractory symptoms. Its place in PST protocols in pediatric oncology should be validated with prospective studies. Our study suggests the potential value of collaboration between palliative care and pain specialists in the context of PST.
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Affiliation(s)
- Andrea Cuviello
- Division of Oncology and Anesthesiology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Melisa Pasli
- Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Shalini Bhatia
- Division of Oncology and Anesthesiology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Liza-Marie Johnson
- Division of Oncology and Anesthesiology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Doralina L. Anghelescu
- Division of Oncology and Anesthesiology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Justin N. Baker
- Division of Oncology and Anesthesiology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Hirata M, Kobayashi K. Experiences with the end-of-life decision-making process in children with cancer, their parents, and healthcare professionals: A systematic review and meta-ethnography. J Pediatr Nurs 2022; 69:e45-e64. [PMID: 36586777 DOI: 10.1016/j.pedn.2022.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Decision-making during the end-of-life (EOL) phase for children with cancer is extremely difficult for parents. We synthesized the qualitative experiences of children with cancer, parents, and healthcare professionals (HCPs), and their social interactions during the EOL decision-making process in the pediatric oncology setting. METHODS Meta-ethnography was used to conduct a systematic review and meta-synthesis. We searched four online databases to identify original studies published in English and Japanese and examined 21 relevant studies. Two Japanese reviewers discussed the differences/relationships and included studies that synthesized the translated qualitative findings. A conceptual model of social interactions was created. RESULTS We identified four themes regarding children's, parents', and HCPs' experiences: hope and confrontation with the child's death, guidance and support during uncertainty, awareness of being protected and having hope, and mutual unspoken integration of values. CONCLUSIONS These themes evince the experiences of children, parents, and HCPs during the EOL decision-making process and suggests a complex three-way social interaction model. While considering such distinctive social interactions during a child's EOL, this study revealed the sharing of prudent information and psychosocial support by HCPs. The findings indicate that hope and uncertainty are key elements for effectively understanding the experiences of children and parents and that EOL decision-making should not be rushed but should be supported by leaving room for uncertainty and acknowledging parents' emotional needs and fostering new hope. Further research into how hope can be further supported in situations that are rife with uncertainty is needed.
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Affiliation(s)
- Mika Hirata
- Department of Nursing, School of Health and Social Services, Saitama Prefectural University, 820 Sannomiya, Koshigaya-shi, Saitama 343-8540, Japan.
| | - Kyoko Kobayashi
- Graduate School of Nursing Science, St. Luke's International University, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan
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Broden EG, Werner-Lin A, Curley MA, Hinds RPS. Shifting and intersecting needs: Parents’ experiences during and following the withdrawal of life sustaining treatments in the paediatric intensive care unit. Intensive Crit Care Nurs 2022; 70:103216. [DOI: 10.1016/j.iccn.2022.103216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 11/05/2022]
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Juárez-Villegas LE, Altamirano-Bustamante MM, Zapata-Tarrés MM. Decision-Making at End-of-Life for Children With Cancer: A Systematic Review and Meta-Bioethical Analysis. Front Oncol 2021; 11:739092. [PMID: 34722289 PMCID: PMC8554195 DOI: 10.3389/fonc.2021.739092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background Evidence shows that medical education includes a variety of basic and clinical skills. Ethical and human values are not typically considered in medical school curricula, and this is evident in medical practice in certain scenarios such as decision-making at pediatric cancer patients' end of life. Methods This study explores a bioethical approach to address complex decision-making at the end of life in children and adolescents with cancer. We are a cross-functional group of scientists from several academic disciplines who conducted a systematic review of the literature using our newly developed meta-bioethical analysis and synthesis of findings. The search was carried out in five databases, resulting in 10 research papers. Following quality screening, seven articles were ultimately selected for further analysis. Results Our focus is on the state of the art to better understand the bioethical deliberation at the end of life in pediatric oncology. Here, we report a systematic review that includes (i) classification of the screened articles by the type of decision-making they use, ii) the system values that are at the core of the decision-making at the end of life, and iii) bioethical and ethical discernment queries. We conclude with a discussion regarding the best practices of ethical discernment and decision-making at the end of life.This study highlights the need to develop more research to better understand the influence and origin of these multidimensional factors determining critical decisions that define the quality of life of patients in a highly sensitive moment. Conclusion We conclude that personal aspects of the physician define their actions more than knowledge or organized structure. It is thus necessary that pediatric oncologists receive ethics and humanistic education.
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Affiliation(s)
- Luis Enrique Juárez-Villegas
- Department of Hematology-Oncology, Hospital Infantil de Mexico Federico Gómez, Mexico City, Mexico.,Master and Doctorate Program in Medical and Health Sciences, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Myriam M Altamirano-Bustamante
- Master and Doctorate Program in Medical and Health Sciences, Universidad Nacional Autónoma de México, Mexico City, Mexico.,Metabolic Diseases Research Unit, Cross-functional Bioethics Group, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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McCarthy MC, De Abreu Lourenco R, McMillan LJ, Meshcheriakova E, Cao A, Gillam L. Finding Out What Matters in Decision-Making Related to Genomics and Personalized Medicine in Pediatric Oncology: Developing Attributes to Include in a Discrete Choice Experiment. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 13:347-361. [DOI: 10.1007/s40271-020-00411-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Snoep MC, Jansen NJ, Groenendaal F. Deaths and end-of-life decisions differed between neonatal and paediatric intensive care units at the same children's hospital. Acta Paediatr 2018; 107:270-275. [PMID: 28871637 PMCID: PMC5813263 DOI: 10.1111/apa.14061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/28/2017] [Accepted: 08/31/2017] [Indexed: 11/30/2022]
Abstract
AIM We compared neonatal deaths and end-of-life decisions in a neonatal intensive care unit (NICU) and paediatric intensive care unit (PICU) in a Dutch tertiary children's hospital. SUBJECTS All 235 full-term infants who died within 28 days of life between 2003 and 2013 in the NICU (n = 199) and PICU (n = 36) were retrospectively studied. RESULTS The median length of stay was three days in the NICU and seven days in the PICU (p = 0.003). The main reasons for NICU stays were asphyxia (52.8%) and congenital malformations (42.2%), and in the PICU, they were congenital malformations (97.2%) and primarily cardiac problems (83.3%, p < 0.001). The median age of death was three days in the NICU and eight days in the PICU (p < 0.001), and mortality despite full intensive care treatment was 4.0% and 25.0%, respectively. Intensive treatment was discontinued because of poor survival chances in 25.1% of NICU and 52.8% of PICU cases (p < 0.001), and care was redirected because of expected poor quality of life in 70.9% and 22.2%, respectively. CONCLUSION Differences between the age at death and end-of-life decisions were found between full-term infants in the NICU and PICU in the same children's hospital. Underlying disorders and doctors' attitudes may have played a role.
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Affiliation(s)
- Maartje C. Snoep
- Department of Neonatology; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
- Paediatric Intensive Care; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
| | - Nicolaas J.G. Jansen
- Paediatric Intensive Care; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
| | - Floris Groenendaal
- Department of Neonatology; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
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Verberne LM, Kars MC, Schouten-van Meeteren AYN, Bosman DK, Colenbrander DA, Grootenhuis MA, van Delden JJM. Aims and tasks in parental caregiving for children receiving palliative care at home: a qualitative study. Eur J Pediatr 2017; 176:343-354. [PMID: 28078429 PMCID: PMC5321698 DOI: 10.1007/s00431-016-2842-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 12/06/2016] [Accepted: 12/23/2016] [Indexed: 11/18/2022]
Abstract
UNLABELLED In paediatric palliative care (PPC), parents are confronted with increasing caregiving demands. More children are cared for at home, and the need for PPC of children is lengthened due to technical and medical improvements. Therefore, a clear understanding of the content of parental caregiving in PPC becomes increasingly important. The objective is to gain insight into parental caregiving based on the lived experience of parents with a child with a life-limiting disease. An interpretative qualitative study using thematic analysis was performed. Single or repeated interviews were undertaken with 42 parents of 24 children with a malignant or non-malignant disease, receiving PPC. Based on their ambition to be a 'good parent', parents caring for a child with a life-limiting disease strived for three aims: controlled symptoms and controlled disease, a life worth living for their ill child and family balance. These aims resulted in four tasks that parents performed: providing basic and complex care, organising good quality care and treatment, making sound decisions while managing risks and organising a good family life. CONCLUSION Parents need early explanation from professionals about balancing between their aims and the related tasks to get a grip on their situation and to prevent becoming overburdened. What is Known: • In paediatric palliative care, parents are confronted with increasing caregiving demands. • Parenting is often approached from the perspective of stress. What is New: • Parents strive for three aims: controlled symptoms and controlled disease, a life worth living for their child and family balance. • Parents perform four tasks: providing basic and complex care, organising good quality care, making decisions while managing risks and organising a good family life. • Professionals need insight into the parents' aims and tasks from the parental perspective to strengthen parents' resilience.
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Affiliation(s)
- Lisa M. Verberne
- 0000000090126352grid.7692.aDepartment of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Marijke C. Kars
- 0000000090126352grid.7692.aDepartment of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
| | - Antoinette Y. N. Schouten-van Meeteren
- 0000000404654431grid.5650.6Department of Pediatric Oncology, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Diederik K. Bosman
- 0000000404654431grid.5650.6Department of Pediatrics, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Derk A. Colenbrander
- 0000000404654431grid.5650.6Department of Pediatrics, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Martha A. Grootenhuis
- 0000000404654431grid.5650.6Psychosocial 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
- 0000000090126352grid.7692.aDepartment of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
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