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Bushroe KM, Crisp KD, Politi MC, Brennan SK, Housten AJ. Evaluating caregiver-clinician communication for tracheostomy placement in the neonatal intensive care unit: a qualitative inquiry. J Perinatol 2024; 44:963-969. [PMID: 37833495 PMCID: PMC11014892 DOI: 10.1038/s41372-023-01793-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/07/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023]
Abstract
OBJECTIVE Identify stakeholders' tracheostomy decision-making information priorities in the Neonatal Intensive Care Unit (NICU). STUDY DESIGN English-speaking caregivers and clinicians who participated in NICU tracheostomy discussions between January 2017 and December 2021 were eligible. They reviewed a pediatric tracheostomy communication guide prior to meeting. Interviews focused on tracheostomy decision-making experiences, communication preferences, and guide perceptions. Interviews were recorded, transcribed, and analyzed using iterative inductive/deductive coding to inform thematic analysis. RESULTS Ten caregivers and nine clinicians were interviewed. Caregivers were surprised by the severity of their child's diagnosis and the intensive home care required, but proceeded with tracheostomy because it was the only chance for survival. All recommended that tracheostomy information be introduced early and in phases. Inadequate communication limited caregivers' understanding of post-surgical care and discharge requirements. All felt a guide could standardize communication. CONCLUSIONS Caregivers seek detailed information regarding expectations after tracheostomy placement in the NICU and at home.
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Affiliation(s)
- Kylie M Bushroe
- Department of Pediatrics, Division of Newborn Medicine, St. Louis Children's Hospital and Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
| | - Kelly D Crisp
- College of Health and Human Sciences, Northern Illinois University, DeKalb, IL, USA
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Mary C Politi
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Steven K Brennan
- Department of Pediatrics, Division of Allergy and Pulmonary Medicine, St. Louis Children's Hospital and Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Ashley J Housten
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Mehta AB, Lockhart S, Lange AV, Matlock DD, Douglas IS, Morris MA. Drivers of Decision-Making for Adult Tracheostomy for Prolonged Mechanical Ventilation: A Qualitative Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.20.24301492. [PMID: 38293156 PMCID: PMC10827243 DOI: 10.1101/2024.01.20.24301492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Background Decision-making about tracheostomy and prolonged mechanical ventilation (PMV) is emotionally complex. Expectations of surrogate decision-makers and physicians rarely align. Little is known about what surrogates need to make goal-concordant decisions. We sought to identify drivers of tracheostomy and PMV decision-making. Methods Using Grounded Theory, we performed a qualitative study with semi-structured interviews with surrogates of patients receiving mechanical ventilation (MV) being considered for tracheostomy and physicians routinely caring for patients receiving MV. Recruitment was stopped when thematic saturation was reached. Separate codebooks were created for surrogate and physician interviews. Themes and factors affecting decision-making were identified and a theoretical model tracheostomy decision-making was developed. Results 43 participants (23 surrogates and 20 physicians) completed interviews. A theoretical model of themes and factors driving decision-making emerged for the data. Hope, Lack of Knowledge & Data, and Uncertainty emerged as the three main themes all which were interconnected with one another and, at times, opposed each other. Patient Wishes, Past Activity/Medical History, Short and Long-Term Outcomes, and Meaningful Recovery were key factors upon which surrogates and physicians based decision-making. The themes were the lens through which the factors were viewed and decision-making existed as a balance between surrogate emotions and understanding and physician recommendations. Conclusions Tracheostomy and prolonged MV decision-making is complex. Hope and Uncertainty were conceptual themes that often battled with one another. Lack of Knowledge & Data plagued both surrogates and physicians. Multiple tangible factors were identified that affected surrogate decision-making and physician recommendations. Implications Understanding this complex decision-making process has the potential to improve the information provided to surrogates and, potentially, increase the goal concordant care and alignment of surrogate and physician expectations. Highlights Decision-making for tracheostomy and prolonged mechanical ventilation is a complex interactive process between surrogate decision-makers and providers.Using a Grounded Theory framework, a theoretical model emerged from the data with core themes of Hope, Uncertainty, and Lack of Knowledge & Data that was shared by both providers and surrogates.The core themes were the lenses through which the key decision-making factors of Patient Wishes, Past Activity/Medical History, Short and Long-Term Outcomes, and Meaningful Recovery were viewed.The theoretical model provides a roadmap to design a shared decision-making intervention to improve tracheostomy and prolonged mechanical ventilation decision-making.
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Kielt MJ, Levin JC. To Trach or Not To Trach: Long-term Tracheostomy Outcomes in Infants with BPD. Neoreviews 2023; 24:e704-e719. [PMID: 37907398 DOI: 10.1542/neo.24-11-e704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
See Bonus NeoBriefs videos and downloadable teaching slides Infants born preterm who are diagnosed with bronchopulmonary dysplasia (BPD) demonstrate a wide spectrum of illness severity. For infants with the most severe forms of BPD, safe discharge from the hospital may only be possible by providing long-term ventilation via a surgically placed tracheostomy. Though tracheostomy placement in infants with BPD is infrequent, recent reports suggest that rates of tracheostomy placement are increasing in this population. Even though there are known respiratory and neurodevelopmental risks associated with tracheostomy placement, no evidence-based criteria or consensus clinical practice guidelines exist to inform tracheostomy placement in this growing and vulnerable population. An incomplete knowledge of long-term post-tracheostomy outcomes in infants with BPD may unduly bias medical decision-making and family counseling regarding tracheostomy placement. This review aims to summarize our current knowledge of the epidemiology and long-term outcomes of tracheostomy placement in infants with BPD to provide a family-centered framework for tracheostomy counseling.
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Affiliation(s)
- Matthew J Kielt
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
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Vo HH, Wilfond BS, Ding Y, Henderson CM, Raisanen JC, Ashwal G, Thomas A, Jabre NA, Shipman KJ, Schrooten A, Shaffer J, Boss RD. Family-Reflections.com: Creating a parent-to-parent web-based tool regarding pediatric home ventilation. PATIENT EDUCATION AND COUNSELING 2023; 114:107855. [PMID: 37348312 DOI: 10.1016/j.pec.2023.107855] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/23/2023] [Accepted: 06/13/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND The decision to initiate pediatric mechanical ventilation via tracheostomy ("home ventilation") is complex and parents often desire information from other parents who have faced this decision. However, parent-to-parent communication is challenging as it is difficult to connect new families to experienced families in ways that optimize informed, balanced decision-making. OBJECTIVE Create a parent-to-parent web-based tool to support decision-making about pediatric home ventilation. PATIENT INVOLVEMENT The tool was created based on interviews and feedback from parents. METHODS We interviewed parents who previously chose for, or against, home ventilation for their child. Interview themes and family comments guided website development. Viewer feedback was solicited via an embedded survey in the tool. RESULTS We created 6 composite character families to communicate 6 themes about home ventilation: 1) Considering treatment options, 2) Talking with medical team, 3) Impact on life at home, 4) Impact on relationships, 5) Experience for the child, and 6) If the child's life is short. Nine families who reviewed the draft tool felt it would have helped with their decision about home ventilation. Specifically, it supported families in thinking through what was "most important about their child's breathing problems" (7 of 9 parents) and feeling "more at peace with the decision" (8 of 9 parents). Between 6/1/20-12/31/22, nearly 5500 viewers have accessed the tool and 56 viewers completed the survey (including 13 families and 39 clinicians). Feedback from experienced families and clinicians reported the tool taught them something new. DISCUSSION This novel parent-to-parent tool shows promise for expanding access to balanced, family-centered information about pediatric home ventilation. PRACTICAL VALUE The diverse stories and decisions let parents access multiple family perspectives. The tool's focus is on family-centric information that parents reported was usually missing from clinician counseling. FUNDING This work was supported by the National Palliative Care Research Center.
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Affiliation(s)
- Holly Hoa Vo
- Pediatrics, University of Washington School of Medicine, 1900 Ninth Avenue, Seattle 98101, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, 1900 Ninth Ave, Seattle 98101, USA.
| | - Benjamin S Wilfond
- Pediatrics, University of Washington School of Medicine, 1900 Ninth Avenue, Seattle 98101, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, 1900 Ninth Ave, Seattle 98101, USA
| | - Yuanyuan Ding
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St., Baltimore, MD 21205, USA
| | - Carrie M Henderson
- Pediatrics, University of Mississippi Medical Center, 2500 N. State Street, Jackson 39216, USA; Center for Bioethics and Medical Humanities, 2500 N. State Street, Jackson 39216, USA
| | - Jessica C Raisanen
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21205, USA
| | - Gary Ashwal
- Booster Shot Media, 1450 2nd Street, Suite 342, Santa Monica, CA 90401, USA
| | - Alex Thomas
- Booster Shot Media, 1450 2nd Street, Suite 342, Santa Monica, CA 90401, USA
| | - Nicholas A Jabre
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21205, USA; Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Kelly J Shipman
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, 1900 Ninth Ave, Seattle 98101, USA
| | | | | | - Renee D Boss
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21205, USA; Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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