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White Makinde K, Silverstein A, Peckham-Gregory E, Kim E, Casas J. Exploring Pediatric Code Status, Advance Care Planning, and Mode of Death Disparities at End of Life. J Pain Symptom Manage 2024:S0885-3924(24)00860-1. [PMID: 39032676 DOI: 10.1016/j.jpainsymman.2024.07.009] [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: 02/13/2024] [Revised: 07/08/2024] [Accepted: 07/11/2024] [Indexed: 07/23/2024]
Abstract
CONTEXT Children from marginalized groups are at risk for worse medical outcomes, yet little is known about their end of life experiences. OBJECTIVE We examine the characteristics of deceased children with a focus on race, ethnicity, and preferred language. METHODS We conducted a cross-sectional study of patients who died at Texas Children's Hospital from 2018 to 2019. Demographics, date of death, and final code status were extracted. Medical complexity prior to admission and mode of death were obtained from chart review. RESULTS We included 433 patients. Over one-third were Hispanic (39.3%) with 42.3% preferring Spanish. The majority were White (61.4%) or Black (21.0%). Most patients had significant medical complexity (52.0%) or were infants in their birth admission (29.4%). Half (52.4%) received palliative care; patients with increased medical complexity were more likely to have palliative care involved (P<0.001). There were no differences in palliative care, code status, or mode of death by race. Hispanic patients were less likely to have a full code status (OR 0.42, 95% CI: 0.25-0.73). Spanish-speaking patients were more likely to have palliative care involvement (OR 2.05, 95% CI: 1.21-3.46) and less likely full code orders (OR 0.24, 95% CI: 0.1-0.63). CONCLUSION Palliative care services are engaged with most children at end of life and is accessible to marginalized patient groups. Spanish-speaking patients have different code status orders and modes of death at end of life. Further studies are needed to elucidate explanatory factors for differences revealed and multicenter studies are needed to characterize more widespread experiences.
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Affiliation(s)
- Keisha White Makinde
- Department of Pediatrics (K.W.M.), Division of Newborn Medicine,Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.
| | - Allison Silverstein
- Department of Pediatrics (A.S.), Section of Palliative Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Erin Peckham-Gregory
- Department of Pediatrics (E.P.G.), Center for Epidemiology and Population Health, Baylor College of Medicine, Houston, Texas, USA
| | - Erin Kim
- McGovern Medical School at UTHealth Houston (E.K.), Houston, Texas, USA
| | - Jessica Casas
- Department of Pediatrics (J.S.), Division of Palliative Care, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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2
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Kim CH, Lee J, Lee JW, Kim MS. The impact of specialized pediatric palliative care on advance care planning and healthcare utilization in children and young adults: a retrospective analysis of medical records of in-hospital deaths. BMC Palliat Care 2024; 23:127. [PMID: 38778335 PMCID: PMC11110344 DOI: 10.1186/s12904-024-01448-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/29/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Pediatric palliative care supports children and young adults with life-limiting conditions and their families, seeking to minimize suffering and enhance quality of life. This study evaluates the impact of specialized palliative care (SPC) on advance care planning (ACP) and patterns of end-of-life care for patients who died in the hospital. METHODS This is a retrospective cohort study of medical records extracted from a clinical data warehouse, covering patients who died aged 0-24 in an academic tertiary children's hospital in South Korea. Participants were categorized into before (2011-2013; pre-period) and after (2017-2019; post-period) the introduction of an SPC service. Within the post-period, patients were further categorized into SPC recipients and non-recipients. RESULTS We identified 274 and 205 patients in the pre-period and post-period, respectively. ACP was conducted more and earlier in the post-period than in the pre-period, and in patients who received palliative care than in those who did not. Patients who received SPC were likely to receive less mechanical ventilation or cardiopulmonary resuscitation and more opioids. A multivariable regression model showed that earlier ACP was associated with not being an infant, receiving SPC, and having a neurological or neuromuscular disease. CONCLUSIONS SPC involvement was associated with more and earlier ACP and less intense end-of-life care for children and young adults who died in the hospital. Integrating palliative care into routine care can improve the quality of end-of-life care by reflecting patients' and their families' values and preferences.
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Affiliation(s)
- Cho Hee Kim
- College of Nursing, Kangwon National University, Chuncheon, Republic of Korea
| | - Jung Lee
- Integrative Care Hub, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Ji Weon Lee
- Integrative Care Hub, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Min Sun Kim
- Integrative Care Hub, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Pediatrics, Seoul National University Hospital, Seoul, Republic of Korea.
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3
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Kegel A, Espinoza J, Rahrig A, Schade-Wills T, Rowan CM. Interventions Performed in Children With Immunocompromised Conditions in the Pediatric Intensive Care Unit Within 48 Hours of Death. J Palliat Med 2024; 27:644-650. [PMID: 38232707 DOI: 10.1089/jpm.2023.0400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Background: Understanding interventions preceding death in children with immunocompromised conditions is important to ensure a peaceful and dignified perideath experience. The aim of this study was to describe the number of interventions performed in the pediatric intensive care unit (PICU) within the 48 hours before death in this population. Methods: This was a single-center, retrospective cohort study of all children with an underlying oncologic, hematologic, or immunologic diagnosis admitted to the PICU for at least 72 hours between 2014 and 2021. Medical records were reviewed for interventions within 48 hours preceding death and for palliative care involvement. Interventions were defined as new or escalations in respiratory support, cardiopulmonary resuscitation (CPR), vascular access, drains, and radiographic studies. Associations were evaluated using simple logistic regression. Results: A total of 55 patients were included in this study. The predominant PICU admission diagnoses were respiratory (51%), followed by shock (25%), and neurologic diagnoses (9%). These predominant diagnoses were similar perideath. At PICU admission, only 1 patient had a do-not-resuscitate (DNR) order. Forty-six percent had a DNR order 48 hours preceding death, and 91% had DNR orders in place at time of death. During the 48-hour period preceding death, 80% of children received at least one intervention. Radiographic studies were the most common, used in 78% of children, followed by respiratory (20%), vascular (16%), CPR (13%), and drain placement (7%). Palliative care was involved in 38% of cases and was associated with a decrease in the number of radiologic interventions (p = 0.028) and CPR (p = 0.026). Conclusions: Children in the PICU with underlying immunocompromised conditions frequently receive interventions within the 48-hour period preceding death. Palliative care involvement was associated with fewer radiographic studies and fewer occurrences of CPR. The impact of interventions on the dying experience warrants further investigation.
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Affiliation(s)
- Anna Kegel
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Jason Espinoza
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - April Rahrig
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Tina Schade-Wills
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, Indiana, USA
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4
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Hodge CH, Kerris EWJ, Freeman MC, Eckman ST, Deeter DM, Even KM. Implementation of an Innovative Palliative Care Screening Tool in the Pediatric Intensive Care Unit: A Pilot Study. J Palliat Med 2024; 27:307-315. [PMID: 37815840 DOI: 10.1089/jpm.2023.0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
Background: Pediatric palliative care (PPC) can improve the quality of care provided to critically ill children with a high risk of morbidity and mortality. Early identification of patients admitted to the pediatric intensive care unit (PICU) who may benefit from PPC involvement is essential. Objectives: To create a brief screening tool, the Pediatric Intensive Care-Pediatric Palliative Care Screen, identifying PICU patients most likely to benefit from PPC involvement and to assess if weekly screening with this screening tool increases the number of PPC consults placed in the PICU. Methods: This is a prospective investigational single-center study in a 24-bed PICU at a U.S. tertiary care children's hospital. Weekly screening was completed by two clinicians for a six-month period between April and October 2022. Results: A total of 162 screens were completed on 124 individual patients; 47 screens were positive (29%), and 115 were negative (71%). Fourteen new PPC consults were placed from the PICU with one PPC consult for every 36.7 compared with one PPC for every 41.4 admissions the previous year. Of the positive screens, 68% had two or more comorbidities at the time of PICU admission versus 26% of negative screens (p < 0.001). Technology dependence (57% vs. 5%, p < 0.001) and presence of congenital defects (26% vs. 10%, p = 0.013) were significantly more common among positive screens. Conclusions: Weekly screening with a short, 7-question screening tool can identify PICU patients most likely to benefit from a PPC consult. Patients with chronic illnesses and baseline comorbidities are most likely to screen positive.
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Affiliation(s)
- Caitlyn H Hodge
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Elizabeth W J Kerris
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Michelle C Freeman
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Susannah T Eckman
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Deana M Deeter
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Katelyn M Even
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
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Iten R, O'Connor M, Gill FJ. Palliative care for infants with life-limiting conditions: integrative review. BMJ Support Palliat Care 2023:spcare-2023-004435. [PMID: 38123923 DOI: 10.1136/spcare-2023-004435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/22/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Infants with life-limiting conditions are a heterogeneous population. Palliative care for infants is delivered in a diverse range of healthcare settings and by interdisciplinary primary healthcare teams, which may not involve specialist palliative care service consultation. OBJECTIVE To synthesise the literature for how palliative care is delivered for infants aged less than 12 months with life-limiting conditions. METHODS An integrative review design. MEDLINE, CINAHL, ProQuest, Cochrane, Joanna Briggs Institute and EMBASE were searched for research published in English language, from 2010 to 2022, and peer reviewed. Critical appraisal was completed for 26 patient case series, 9 qualitative, 5 cross-sectional and 1 quality improvement study. Data analysis involved deductive content analysis and narrative approach to summarise the synthesised results. RESULTS 37 articles met the eligibility for inclusion. Two models of palliative care delivery were examined, demonstrating differences in care received and experiences of families and health professionals. Health professionals reported lack of palliative care education, challenges for delivering palliative care in intensive care settings and barriers to advance care planning including prognostic uncertainty and transitioning to end-of-life care. Families reported positive experiences with specialist palliative care services and challenges engaging in advance care planning discussions. CONCLUSION There are complex issues surrounding the provision of palliative care for infants. Optimal palliative care should encompass a collaborative and coordinated approach between the primary healthcare teams and specialist palliative care services and prioritisation of palliative care education for nurses and physicians involved in providing palliative care to infants.
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Affiliation(s)
- Rebecca Iten
- Curtin University, Perth, Western Australia, Australia
- Perth Children's Hospital, Nedlands, Western Australia, Australia
| | | | - Fenella J Gill
- Curtin University, Perth, Western Australia, Australia
- Perth Children's Hospital, Nedlands, Western Australia, Australia
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6
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Lusney N, van Breemen C, Lim E, Pawliuk C, Hussein Z. Pediatric Advance Care Planning: A Scoping Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1179. [PMID: 37508676 PMCID: PMC10378635 DOI: 10.3390/children10071179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023]
Abstract
To assess current practice and provide a basis for a provincial template, clinicians at a Canadian pediatric hospice reviewed the literature surrounding pediatric advance care planning (pACP) documentation, process, and implementation for children/youth. The scoping review protocol was developed in accordance with the Joanna Briggs Institute methodology for scoping reviews, and was prospectively registered on the Open Science Framework. MEDLINE, Embase, CINAHL, the Web of Science Core Collection, and Google Scholar, as well as sources of unpublished studies and grey literature, were reviewed. Sixty-four articles met the criteria. Fifteen pACP documentation forms/tools were also identified. Overall, the included articles highlighted that pACP should be a structured, collaborative and iterative process between the family and a trusted or relevant healthcare provider, encompassing medical and non-medical issues. Few articles provided insights into specific elements recommended for advance directive forms. Identified strategies for implementation included a structured, step-by-step pACP interventional tool along with ongoing training, mentorship, and defined organizational structures for the clinician. No single specific ACP tool was acknowledged as the gold standard. Use of a pACP tool, along with ongoing provider education and communication skill development, standardized/accessible documentation, and system-wide quality improvement support, were noted as integral components of pACP.
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Affiliation(s)
- Nadine Lusney
- Canuck Place Children's Hospice, Vancouver, BC V6J 2T2, Canada
| | - Camara van Breemen
- Canuck Place Children's Hospice, Vancouver, BC V6J 2T2, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Edlyn Lim
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Colleen Pawliuk
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Zahra Hussein
- Child Health British Columbia, Vancouver, BC V6J 4Y6, Canada
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7
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Lotstein D, Klein MJ, Lindley LC, Wolfe J. From Hospital to Home: Referrals to Pediatric Hospice and Home-based Palliative Care. J Pain Symptom Manage 2023; 65:570-579. [PMID: 36828291 DOI: 10.1016/j.jpainsymman.2023.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
CONTEXT Hospital-based pediatric palliative care (PPC) may help optimize referrals to community-based hospice and home-based palliative care (HBPC) for children with serious illness, yet little is known about their referral practices. OBJECTIVES To describe community-based program referrals from a PPC team, identifying factors associated with referral type, and potential misalignment between patient needs and referral received. METHODS Chart abstraction of patients seen in 2017 by the PPC team of a large, urban children's hospital, followed for at least 6 months or until death, including clinical and demographic characteristics, and referrals to hospice and HBPC. RESULTS Of the 302 study-eligible patients, 25% died during the hospitalization of the first 2017 visit. Of the remaining 228 patients, 42 (18.4%) were referred to HBPC and 58 (25.4%) to hospice. Excluding patients referred to hospice care, only one-third with demographic eligibility were referred to HBPC; those seen in the ICU were least likely to be referred. Over half of the 58 patients referred to hospice died within the study period (n = 34, 58.6%); descendants were more likely to have cancer (P = 0.002) and less likely to have a neurologic (P = 0.021) diagnosis. CONCLUSION Despite demographic eligibility, a minority of patients seen by a hospital-based PPC team received referrals for hospice or HBPC. Children discharged from an ICU and those with neurologic conditions may be at higher risk of missing referrals best aligned with their needs. Future research should identify and address causes of referral misalignment. Advocacy for programs adaptable to patients' changing needs may also be needed.
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Affiliation(s)
- Debra Lotstein
- Division of Comfort and Palliative Care, Department of Anesthesia Critical Care Medicine (D.L.), Children's Hospital Los Angeles, Los Angeles, CA, USA and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
| | - Margaret J Klein
- Department of Anesthesia Critical Care Medicine (M.J.K.), Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Lisa C Lindley
- College of Nursing, University of Tennessee (L.C.L.), Knoxville, Tennessee, USA
| | - Joanne Wolfe
- Department of Pediatrics (J.W.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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8
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Cicozi K, Smith SM, Grossoehme DH, Hiltunen A, Roth C, Richner G, Kim SS, Friebert S. Pediatric Home-Based Hospice and Palliative Medicine Provider Home Visits: A Multisite Study. J Palliat Med 2023. [PMID: 36695724 DOI: 10.1089/jpm.2022.0480] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: Pediatric home-based palliative care and/or hospice provider (Physician, Advanced Practice Nurse, or Physician Assistant) home visits are an underexplored subject in the literature with little available descriptive data and limited evidence guiding how best to utilize them. Objectives: Describe the population receiving hospice and palliative medicine (HPM) provider home visits and characterize visit themes. Design: Retrospective chart review of electronic medical record (EMR) data Setting/Subjects: A total of 226 individuals 1 month to 21 years of age, who received an HPM provider home visit from January 1, 2013, to December 31, 2018; two large quaternary medical centers in the Midwest. Measurements: Demographic data, content, and details from home visit abstracted from the EMR. Results: The three most common diagnostic groups receiving HPM provider home visits were neurological (42%), congenital chromosomal (26%), and prematurity-related (14%) conditions. Goals of care (GOC) were discussed at 29% of visits; most commonly, goals related to code status (42%), technology dependence (20%), and nutrition/hydration (15%). A change in GOC occurred in 44% of visits. Forms of anticipatory guidance addressed were nutrition (68%), side effects of treatment (63%), pain assessment (59%), decline/death (32%), and allow natural death/do not resuscitate/advance directives (26%). Conclusion: HPM provider visits are diverse in content and changes in plan of care with potential for proactive identification of GOC and provision of important anticipatory guidance around patient decline and end of life. Further research is indicated to establish which populations benefit most and how to leverage this scarce resource strategically.
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Affiliation(s)
- Kate Cicozi
- Department of Anesthesia, Section of Hospice and Palliative Care, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Steven M Smith
- Department of Anesthesia, Section of Hospice and Palliative Care, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Daniel H Grossoehme
- Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, Ohio, USA.,Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, Ohio, USA
| | - Audrey Hiltunen
- Department of Anesthesia, Section of Hospice and Palliative Care, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Catherine Roth
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Gwendolyn Richner
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, Ohio, USA
| | - Stephani S Kim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sarah Friebert
- Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, Ohio, USA.,Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, Ohio, USA
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9
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Rosa WE, Izumi S, Sullivan DR, Lakin J, Rosenberg AR, Creutzfeldt CJ, Lafond D, Tjia J, Cotter V, Wallace C, Sloan DE, Cruz-Oliver DM, DeSanto-Madeya S, Bernacki R, Leblanc TW, Epstein AS. Advance Care Planning in Serious Illness: A Narrative Review. J Pain Symptom Manage 2023; 65:e63-e78. [PMID: 36028176 PMCID: PMC9884468 DOI: 10.1016/j.jpainsymman.2022.08.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility. OBJECTIVE To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness. METHODS We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care. RESULTS Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations. CONCLUSIONS We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.
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Affiliation(s)
- William E Rosa
- Department of Psychiatry and Behavioral Sciences (W.E.R.), Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Shigeko Izumi
- School of Nursing (S.I.), Oregon Health and Science University, Portland, Oregon
| | - Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine (D.R.S.), School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Joshua Lakin
- Department of Psychosocial Oncology and Palliative Care (J.L., R.B.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Abby R Rosenberg
- Division of Hematology-Oncology, Department of Pediatrics (A.R.R.), University of Washington School of Medicine, Seattle, Washington; Palliative Care and Resilience Lab (A.R.R.), Seattle Children's Research Institute, Seattle, Washington
| | | | - Debbie Lafond
- Pediatric and Neonatal Needs Advanced (PANDA) Education Consultants (D.L.)
| | - Jennifer Tjia
- Chan Medical School, University of Massachusetts (J.T.), Worcester, Massachusetts
| | - Valerie Cotter
- School of Nursing, Johns Hopkins University (V.C.), Baltimore, Maryland; School of Medicine, Johns Hopkins University (V.C.), Baltimore, Maryland
| | - Cara Wallace
- College for Public Health and Social Justice (C.W.), Saint Louis University, St. Louis, Missouri
| | - Danetta E Sloan
- Department of Health (D.E.S.), Behavior and Society, Johns Hopkins University, Baltimore, Maryland
| | - Dulce Maria Cruz-Oliver
- Geriatric Medicine and Gerontology (D.M.C.O.), Beacham Center for Geriatric Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care (J.L., R.B.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Thomas W Leblanc
- Department of Medicine (T.W.L.), Duke University School of Medicine, Durham, North Carolina
| | - Andrew S Epstein
- Department of Medicine (A.S.E.), Memorial Sloan Kettering Cancer Center, New York, New York
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10
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Iten R, O'Connor M, Cuddeford L, Gill FJ. Care management trajectories of infants with life-limiting conditions who died before 12 months of age; a retrospective patient health record review. J Pediatr Nurs 2022; 70:e22-e31. [PMID: 36463014 DOI: 10.1016/j.pedn.2022.11.014] [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: 05/08/2022] [Revised: 10/11/2022] [Accepted: 11/11/2022] [Indexed: 12/02/2022]
Abstract
PURPOSE To characterise the care management trajectories of infants with life-limiting conditions, who died before 12 months, including clinical decision-making processes, identification of triggers that led to changes in care management from cure-orientated to palliative care and specialist palliative care team involvement. DESIGN AND METHODS Retrospective patient health record review of infants with life-limiting conditions who died before 12 months of age and received care at three hospitals in Western Australia. Two data analysis methods; directed content analysis and process mapping. RESULTS A total of 45 patient health records were reviewed. Process mapping led to typology of care management encompassing four trajectories; early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until a significant point; and early treatment limits. Standardised advance care planning processes were used for just over 10% of infants. There was specialist palliative care team involvement for 25% of infants. CONCLUSION Only a proportion of infants received early integration of palliative care principles and practices. Infants and their families may benefit from earlier integration of palliative care, and standardised processes for advance care planning that are done in parallel to treatment. PRACTICE IMPLICATIONS There is opportunity to further enhance the delivery of palliative care to infants with life-limiting conditions and optimise the experience for families through education for health professionals, implementation of advance care planning and standardisation through policies and clinical practice guidelines.
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Affiliation(s)
- Rebecca Iten
- School of Nursing, Faculty Health Sciences, Curtin University, Perth 6102, WA, Australia; Perth Children's Hospital, Child and Adolescent Health Service, 15 Hospital Avenue, Nedlands 6009, WA, Australia.
| | - Moira O'Connor
- School of Population Health, Faculty Health Science, Curtin University, Perth 6102, WA, Australia.
| | - Lisa Cuddeford
- Perth Children's Hospital, Child and Adolescent Health Service, 15 Hospital Avenue, Nedlands 6009, WA, Australia.
| | - Fenella J Gill
- School of Nursing, Faculty Health Sciences, Curtin University, Perth 6102, WA, Australia; Perth Children's Hospital, Child and Adolescent Health Service, 15 Hospital Avenue, Nedlands 6009, WA, Australia; Enable Institute, Curtin University, Perth 6102, WA, Australia.
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11
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Riiser K, Holmen H, Winger A, Steindal SA, Castor C, Kvarme LG, Lee A, Lorentsen VB, Misvaer N, Früh EA. Stories of paediatric palliative care: a qualitative study exploring health care professionals' understanding of the concept. BMC Palliat Care 2022; 21:187. [PMID: 36273144 PMCID: PMC9587603 DOI: 10.1186/s12904-022-01077-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/30/2022] Open
Abstract
Background By sharing patient stories, health care professionals (HCPs) may communicate their attitudes, values and beliefs about caring and treatment. Previous qualitative research has shown that HCPs usually associate paediatric palliative care (PPC) with death or dying and that they find the concept challenging to understand and difficult to implement. Attending to HCPs’ stories may provide a richer account of their understanding of PPC. Thus, the aim of this study was to explore PPC stories narrated by HCPs to gain increased insight into their understanding of what PPC entails. Methods This qualitative study collected data from four focus group interviews with 21 HCPs from different units in two Norwegian hospitals. Stories told by the HCPs to illustrate their comprehension of PPC were analysed following thematic analysis procedures. Results Four themes were identified illustrating what PPC meant to the participants: creating spaces for normality, providing tailored support for the family, careful preparations for saying goodbye and experiencing dilemmas and distress. The stories centred on family care, particularly relating to dramatic or affective situations when the death of a child was imminent. Conclusion The stories reflect how the HCPs view PPC as a specific field of health care that requires particular professional sensitivity, including good communication, collaboration and planning. Thus, the HCPs in this study demonstrated knowledge about the core qualities needed to succeed in PPC. However, similar to previous research, the stories illustrate that how HCPs speak about PPC is strongly associated with end-of-life care, and by that the HCPs do not capture the breadth of the PPC concept. The findings highlight the importance of increasing knowledge about the meaning and content of PPC among HCPs in order to maintain quality of life for all children with life-limiting or life-threatening conditions throughout their illness trajectory.
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Affiliation(s)
- Kirsti Riiser
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, St. Olavs plass, NO-0130, Oslo, PO Box 4, Norway.
| | - Heidi Holmen
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, St. Olavs plass, NO-0130, Oslo, PO Box 4, Norway
| | - Anette Winger
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, St. Olavs plass, NO-0130, Oslo, PO Box 4, Norway
| | - Simen A Steindal
- Lovisenberg Diaconal University College, Lovisenberggt. 15b, NO-0456, Oslo, Norway
| | - Charlotte Castor
- Department of Health Sciences, Faculty of Medicine, Lund University, SE-221 00, Lund, Box 157, Sweden
| | - Lisbeth Gravdal Kvarme
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, St. Olavs plass, NO-0130, Oslo, PO Box 4, Norway
| | - Anja Lee
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, NO-0424, Ullevål, Nydalen, Oslo, PO Box 4950, Norway
| | - Vibeke Bruun Lorentsen
- Department of Nursing, Faculty of Health Studies, VID Specialized University, NO-0319, Vinderen, Oslo, PO Box 184, Norway
| | - Nina Misvaer
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, St. Olavs plass, NO-0130, Oslo, PO Box 4, Norway
| | - Elena Albertini Früh
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, St. Olavs plass, NO-0130, Oslo, PO Box 4, Norway
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12
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Zimmermann K, Marfurt-Russenberger K, Cignacco E, Bergstraesser E. Bereaved parents' perspectives on their child's end-of-life care: connecting a self-report questionnaire and interview data from the nationwide Paediatric End-of-LIfe CAre Needs in Switzerland (PELICAN) study. Palliat Care 2022; 21:66. [PMID: 35509046 PMCID: PMC9066872 DOI: 10.1186/s12904-022-00957-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 04/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Paediatric Palliative Care (PPC) focuses on ensuring the best possible quality of life for the child and his/her family by extending beyond the physical domain into psychosocial and spiritual wellbeing. A deep understanding of what is important to parents is crucial in guiding the further evaluation and improvement of PPC and end-of-life (EOL) care services. Much can be learned from specific positive and negative experiences of bereaved parents with the EOL care of their child. This report builds upon a questionnaire survey as part of the national Paediatric End-of-LIfe CAre Needs in Switzerland (PELICAN) study. Methods One part of the PELICAN study was set up to assess and explore the parental perspectives on their child’s EOL care. Interview data were used to explain the extremely positive and negative results of a quantitative survey in an explanatory sequential mixed-methods approach. Data integration occurred at different points: during sampling of the interview participants, when designing the interview guide and during analysis. A narrative approach was applied to combine the qualitative results reported here with the already published quantitative survey results. Results Eighteen mothers (60%) and twelve fathers (40%) participated in 20 family interviews. All parents reported having both positive and negative experiences during their child’s illness and EOL, which was characterised by many ups and downs. The families transitioned through phases with a prospect of a cure for some children as well as setbacks and changing health status of the child which influenced prognosis, leading to the challenge of making extremely difficult decisions. Severely negative experiences still haunted and bothered the parents at the time when the interview took place. Conclusions A deep understanding of the perspectives and needs of parents going through the devastating event of losing a child is important and a prerequisite to providing compassionate care. This complex care needs to recognise and respond to the suffering not only of the child but of the parents and the whole family. Communication and shared decision-making remain pivotal, as do still improvable elements of care that should build on trustful relationships between families and healthcare professionals.
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Affiliation(s)
- Karin Zimmermann
- Department Public Health (DPH), Nursing Science, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland. .,Paediatric Palliative Care and Children's Research Center CRC, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.
| | | | - Eva Cignacco
- Health Department, Bern University of Applied Sciences, Bern, Switzerland
| | - Eva Bergstraesser
- Paediatric Palliative Care and Children's Research Center CRC, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland
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13
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Dinkelbach L, Galushko M, Oommen-Halbach A, Felek M, Dechert O, Trocan L, Janßen G. Advance care planning and the parental geographical background in pediatric palliative home care: a retrospective chart review. Eur J Pediatr 2022; 181:2789-2797. [PMID: 35507218 PMCID: PMC9192398 DOI: 10.1007/s00431-022-04469-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/24/2022] [Accepted: 04/05/2022] [Indexed: 11/24/2022]
Abstract
The relevance to acknowledge the parental migration history in pediatric palliative care is widely recognized. However, its influence on integral parts of advance care planning (ACP) is unknown. In this non-interventional cohort study, we aimed at identifying systematic differences between pediatric palliative patients with varying parental countries of origin regarding medical orders for life-sustaining treatment and the location of patients' death. Two hundred eighty-eight pediatric cases in an ambulant pediatric palliative care setting in Germany were retrospectively analyzed using multinomial logistic regression models. Agreements on medical orders for life-sustaining treatment (MOLST) differed significantly between patients with varying parental countries of origin. Full code orders for life-sustaining treatment were made more often in Turkish families than in German families. There were no significant associations between the patients' location of death and the parental countries of origin. However, confounder-analysis revealed a strong association between the patients' underlying disease and the orders for life-sustaining treatment as well as the location of death.Conclusions: Even this study indicates that the parental geographical background as an important sociocultural aspect might have an impact on ACP decisions for children and adolescents with life-limiting conditions, other factors as the patients' underlying disease can be more crucial for decision making in pediatric palliative care. The reason for the differences found might lay in cultural preferences or barriers to appropriate care. The inclusion of sociocultural aspects in decision-making is crucial to guarantee culture-sensitive, patient-centered pediatric palliative care.
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Affiliation(s)
- Lars Dinkelbach
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Centre for Child and Adolescent Health, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany. .,Centre for Child and Adolescent Health, HELIOS Klinikum Krefeld, Lutherplatz 40, 47805, Krefeld, Germany.
| | - Maren Galushko
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Centre for Child and Adolescent Health, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Anne Oommen-Halbach
- Department of the History, Philosophy and Ethics of Medicine, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Melisa Felek
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Centre for Child and Adolescent Health, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Oliver Dechert
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Centre for Child and Adolescent Health, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Laura Trocan
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Centre for Child and Adolescent Health, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Gisela Janßen
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Centre for Child and Adolescent Health, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
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14
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Woodruff AG, Bingham SB, Jarrah RJ, Bass AL, Nageswaran S. A Framework for Pediatric Intensivists Providing Compassionate Extubation at Home. Pediatr Crit Care Med 2021; 22:454-461. [PMID: 33443980 DOI: 10.1097/pcc.0000000000002655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For families facing end-of-life decisions for their critically ill children, compassionate extubation at home is a valuable service that pediatric intensivists can provide. Compassionate extubation at home is resource intensive and can be logistically challenging. Discouragingly, guidance on compassionate extubation at home in the literature is limited. We developed an evidence- and experience-based framework for compassionate extubation at home addressing common planning challenges and resource management. Our objective is to share this framework and an accompanying checklist, so that pediatric intensivists in other institutions can adapt these tools for their use, reducing barriers to providing compassionate extubation at home for critically ill children at the end of life.
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Affiliation(s)
- Alan G Woodruff
- Department of Anesthesiology, Section of Pediatric Critical Care, Wake Forest School of Medicine, Winston-Salem, NC
| | - Sarah B Bingham
- Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Rima J Jarrah
- Department of Anesthesiology, Section of Pediatric Critical Care, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Emergency Medicine, Brenner Children's Hospital, Pediatric Critical Care Transport, Winston-Salem, NC
| | - Andora L Bass
- Department of Anesthesiology, Section of Pediatric Critical Care, Wake Forest School of Medicine, Winston-Salem, NC
| | - Savithri Nageswaran
- Department of Pediatrics, Section of Pediatric Palliative and Complex Care, Wake Forest School of Medicine, Winston-Salem, NC
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15
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Variation in Pediatric Palliative Care Allocation Among Critically Ill Children in the United States. Pediatr Crit Care Med 2021; 22:462-473. [PMID: 33116070 DOI: 10.1097/pcc.0000000000002603] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The objectives are as follows: 1) estimate palliative care consult rates and trends among critically ill children and 2) characterize which children receive palliative care consults, including those meeting previously proposed ICU-specific palliative care screening criteria. DESIGN Retrospective cohort. SETTING Fifty-two United States children's hospitals participating in the Pediatric Health Information Systems database. PATIENTS Hospitalized children with nonneonatal ICU admissions from 2007 to 2018. MEASUREMENTS AND MAIN RESULTS The primary outcome was palliative care consultation, as identified by the palliative care International Classification of Disease code. Patient characteristics and outcomes were compared between those with and without palliative care. We used a mixed-effects multivariable model to estimate the independent association between the palliative care and patient characteristics accounting for institution and subject clustering. Hospitalizations were categorized into three mutually exclusive groups for comparative analyses: 1) meeting ICU-specific palliative care criteria, 2) presence of a complex chronic condition not in ICU-specific palliative care criteria, or 3) not meeting ICU-specific palliative care or complex chronic condition criteria. Rates and trends of palliative care consultation were estimated including variation among institutions and variation among subcategories of ICU-specific palliative care criteria. The study cohort included 740,890 subjects with 1,024,666 hospitalizations. About 1.36% of hospitalizations had a palliative care consultation. Palliative care consult was independently associated with older age, female sex, government insurance, inhospital mortality, and ICU-specific palliative care or complex chronic condition criteria. Among the hospitalizations, 30% met ICU-specific palliative care criteria, 40% complex chronic condition criteria, and 30% neither. ICU-specific palliative care patients received more mechanical ventilation and cardiopulmonary resuscitation, had longer hospital and ICU lengths of stay, and had higher inhospital mortality (p < 0.001). Palliative care utilization increased over the study period with considerable variation between the institutions especially in the ICU-specific palliative care cohort and its subgroups. CONCLUSIONS Palliative care consultation for critically ill children in the United States is low. Palliative care utilization is increasing but considerable variation exists across institutions, suggesting inequity in palliative care allocation among this vulnerable population. Future studies should evaluate factors influencing allocation of palliative care among critically ill children in the United States and the drivers of differences between the institutional practices.
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16
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Beltran SJ, Hamel MN. Caring for Dying Infants: A Systematic Review of Healthcare Providers’ Perspectives of Neonatal Palliative Care. Am J Hosp Palliat Care 2020; 38:1013-1027. [DOI: 10.1177/1049909120965949] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: The palliative and hospice care movement has expanded significantly in the United States since the 1960s. Neonatal end of life care, in particular, is a developing area of practice requiring healthcare providers to support terminally ill newborns and their families, to minimize suffering at the end of the neonate’s life. This paper seeks to systematically summarize healthcare providers’ perspectives related to end of life, in order to identify needs and inform future directions. Methods: Informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically reviewed the literature discussing healthcare provider perspectives of neonatal end of life care ranging from year 2009 to 2020. To be included in the review, articles had to explicitly focus on perspectives of healthcare providers toward neonatal end of life care, be published in academic peer-reviewed sources, and focus on care in the United States. Results: Thirty-three articles were identified meeting all inclusion criteria. The literature covers, broadly, provider personal attitudes, experiences delivering care, practice approaches and barriers, and education and training needs. The experiences of physicians, physician assistants, nurse practitioners, and nurses are highlighted, while less is discussed of other providers involved with this work (e.g., social work, physical therapy). Conclusion: Future research should focus on developing and testing interventions aimed at training and supporting healthcare providers working with neonates at end of life, as well as addressing barriers to the development and implementation of neonatal palliative teams and guidelines across institutions.
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Affiliation(s)
| | - Marie Nicole Hamel
- Burnett School of Biomedical Sciences, University of Central Florida, Orlando, FL, USA
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17
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Song IG, Kang SH, Kim MS, Kim CH, Moon YJ, Lee J. Differences in perspectives of pediatricians on advance care planning: a cross-sectional survey. BMC Palliat Care 2020; 19:145. [PMID: 32948177 PMCID: PMC7500719 DOI: 10.1186/s12904-020-00652-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/10/2020] [Indexed: 12/03/2022] Open
Abstract
Background The increase in the number of pediatric patients with complex health conditions necessitates the application of advance care planning for children. Earlier, withdrawal of life-sustaining treatment was taboo in the medical society in South Korea due to the history of such practice being punishable by law, and physicians tended to pursue aggressive treatment. With changes in public opinion on end-of-life care, the Korean government enacted a new law that protect human dignity by respecting patients’ self-determination and facilitating advance care planning. However, little is known about current state of advance care planning for pediatric patients. The study aimed to assess perceptions regarding advance care planning among South Korean pediatricians and clarify any differences in perception among pediatric subspecialties. Methods This study was an observational cross-sectional survey that used a web-based self-report questionnaire. Participants comprised of pediatricians currently caring for children with life-limiting conditions in 2018. Results Of the 96 respondents, 89 were included in the analysis. In a hypothetical patient scenario, more hemato-oncologists and intensivists than neonatologists and neurologists preferred to provide comfort care than aggressive treatment. While 72.2% of hemato-oncologists reported that they usually or always discuss advance care plans with parents during treatment, more than half of other pediatricians reported that they seldom do so. Furthermore, 65% of respondents said that they never discuss advance care planning with adolescent patients. Moreover, there were no notable differences among subspecialties. The most prevalent answers to factors impeding advance care planning were lack of systemic support after performing advance care planning (82.0%) and uncertain legal responsibilities (70.8%). Conclusions The pediatricians differed in their experiences and attitudes toward advance care planning based on their subspecialty. Consequently, institutional support and education should be provided to physicians so that they can include children and families in discussions on prognosis.
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Affiliation(s)
- In Gyu Song
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Han Kang
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Min Sun Kim
- Department of Pediatrics, Seoul National University Children's Hospital, 101, Daehak-ro, Jungno-gu, Seoul, 03080, South Korea.
| | - Cho Hee Kim
- College of Nursing, Seoul National University, Seoul, South Korea
| | - Yi Ji Moon
- Integrative Care Hub, Seoul National University Children's Hospital, Seoul, South Korea
| | - Jung Lee
- Integrative Care Hub, Seoul National University Children's Hospital, Seoul, South Korea
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18
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Lord S, Moore C, Beatty M, Cohen E, Rapoport A, Hellmann J, Netten K, Amin R, Orkin J. Assessment of Bereaved Caregiver Experiences of Advance Care Planning for Children With Medical Complexity. JAMA Netw Open 2020; 3:e2010337. [PMID: 32721029 PMCID: PMC7388020 DOI: 10.1001/jamanetworkopen.2020.10337] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE Advance care planning (ACP) is the process of discussing values and preferences for care to help inform medical decision-making. Children with medical complexity (CMC) often have a shortened life span with an unpredictable clinical course and timing of death; however, there is a paucity of literature that describes the experience of ACP from the perspective of bereaved family caregivers of CMC. OBJECTIVE To explore the experiences of bereaved family caregivers with ACP for CMC. DESIGN, SETTING, AND PARTICIPANTS This qualitative study included 12 interviews with 13 bereaved family caregivers of CMC whose deaths had occurred in the 5 years before study commencement (2013-2018). Participants were recruited at a single tertiary care pediatric center; CMC were treated by the Complex Care or Long-term Ventilation clinic in Toronto, Ontario, Canada. Data were collected from July to October 2018. Thematic analysis with an inductive approach was used. EXPOSURES Qualitative interviews were conducted using purposive sampling of bereaved family caregivers using semistructured interviews that were recorded and transcribed. Interviews were conducted until saturation was reached. MAIN OUTCOMES AND MEASURES Transcripts were analyzed to create themes that characterized caregiver experiences with ACP. RESULTS A total of 13 family caregivers were interviewed in 12 interviews, all of whom were parents (12 [92%] women, 1 [8%] man) of a deceased child (aged 7 months to 12 years). Themes were divided in the 3 following categories, which align with the Donabedian model for health service quality: (1) structure of care, (2) ACP process, and (3) end-of-life experience. Notable subthemes for this population included the importance of accounting for parental expertise in the child's care, recurrent experiences with life-threatening events, relative shock of the timing of death, and the multiple losses that caregivers experienced. CONCLUSIONS AND RELEVANCE In this study, parental experiences revealed that there are key aspects of the structure of the child's care, process around ACP, and end-of-life care experiences that provide important reflections on ACP that warrant future study.
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Affiliation(s)
- Sarah Lord
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Clara Moore
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Madison Beatty
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Eyal Cohen
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Adam Rapoport
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Emily’s House Children’s Hospice, Toronto, Ontario, Canada
| | - Jonathan Hellmann
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kathy Netten
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Reshma Amin
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Julia Orkin
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
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