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Bogetz J, Oslin E, Barton KS, Trowbridge A, Yi-Frazier J, Watson RS, Rosenberg AR. Stress Among Parents of Children With Severe Neurological Impairment in the Pediatric Intensive Care Unit. J Palliat Med 2024; 27:869-878. [PMID: 38546796 DOI: 10.1089/jpm.2023.0683] [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: 07/26/2024] Open
Abstract
Background: Children with severe neurological impairment (SNI) often receive care in the pediatric intensive care unit (PICU), yet little is known about their parents' experiences. Objective: To examine sources of and changes in stress among parents of children with SNI in the PICU. To compare stressors with "good parent" attributes that describe duties parents aim to uphold for their child. Design/Setting/Subjects: Prospective mixed-methods cohort study at a single U.S. children's hospital. Participants included English-speaking parents/legal guardians of a child with SNI with an expected length of stay >1 week and life expectancy >4 weeks. Measurements: Ten-point stress scale administered at PICU admission and discharge with open-ended response items. A subset of parents completed 1:1 semistructured interviews. Data were integrated to examine differences among participants whose stress increased, stayed the same, or decreased, and themes were compared with "good parent" attributes. Results: Twenty-five parents/legal guardians completed the surveys; 15 completed the interviews. Children were a median of 7 years old (interquartile range [IQR] 4, 9; range 1-21) and had a median PICU length of stay of 10 days (IQR 7, 15; range 3-62). Twenty percent (n = 5) of parents were fathers, and 36% (n = 9) had a minority racial/ethnic background. Stress was moderate at admission (mean 6.8, standard deviation [SD] ±1.7) and discharge (mean 6, SD ±2); 32% (n = 8) reported stress trajectories that stayed the same or increased. Major themes included uncertainty, advocacy, and vulnerability and related closely to "good parent" attributes. Conclusion: Stress among parents of children with SNI related to uncertainty, advocacy, and vulnerability and suggested tensions with "good parent" attributes.
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Affiliation(s)
- Jori Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Ellie Oslin
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Krysta S Barton
- Biostatistics Epidemiology and Analytics for Research (BEAR) Core, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Amy Trowbridge
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Joyce Yi-Frazier
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - R Scott Watson
- Division of Critical Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Abby R Rosenberg
- Division of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Palliative Care and Resilience Lab, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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2
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Nelson KE, Zhu J, Thomson J, Mahant S, Widger K, Feudtner C, Cohen E, Pullenayegum E, Feinstein JA. Recurrent Intensive Care Episodes and Mortality Among Children With Severe Neurologic Impairment. JAMA Netw Open 2024; 7:e241852. [PMID: 38488795 PMCID: PMC10943411 DOI: 10.1001/jamanetworkopen.2024.1852] [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: 11/21/2023] [Accepted: 01/05/2024] [Indexed: 03/17/2024] Open
Abstract
Importance Children requiring care in a pediatric intensive care unit (PICU) are known to have increased risk of subsequent mortality. Children with severe neurologic impairment (SNI)-who carry neurologic or genetic diagnoses with functional impairments and medical complexity-are frequently admitted to PICUs. Although recurrent PICU critical illness episodes (PICU-CIEs) are assumed to indicate a poor prognosis, the association between recurrent PICU-CIEs and mortality in this patient population is poorly understood. Objective To assess the association between number of recent PICU-CIEs and survival among children with severe neurologic impairment. Design, Setting, and Participants This population-based retrospective cohort study used health administrative data from April 1, 2002, to March 31, 2020, on 4774 children born between 2002 and 2019 with an SNI diagnosis code in an Ontario, Canada, hospital record before 16 years of age and a first PICU-CIE from 2002 to 2019. Data were analyzed from November 2021 to June 2023. Exposure Pediatric intensive care unit critical illness episodes (excluding brief postoperative PICU admissions). Main Outcome and Measures One-year survival conditioned on the number and severity (length of stay >15 days or use of invasive mechanical ventilation) of PICU-CIEs in the preceding year. Results In Ontario, 4774 children with SNI (mean [SD] age, 2.1 [3.6] months; 2636 [55.2%] <1 year of age; 2613 boys [54.7%]) were discharged alive between 2002 and 2019 after their first PICU-CIE. Ten-year survival after the initial episode was 81% (95% CI, 79%-82%) for children younger than 1 year of age and 84% (95% CI, 82%-86%) for children 1 year of age or older; the age-stratified curves converged by 15 years after the initial episode at 79% survival (95% CI, 78%-81% for children <1 year and 95% CI, 75%-84% for children ≥1 year). Adjusted for age category and demographic factors, the presence of nonneurologic complex chronic conditions (adjusted hazard ratio [AHR], 1.70 [95% CI, 1.43-2.02]) and medical technology assistance (AHR, 2.32 [95% CI, 1.92-2.81]) were associated with increased mortality. Conditional 1-year mortality was less than 20% regardless of number or severity of recent PICU-CIEs. Among children with high-risk PICU-CIEs, 1-year conditional survival decreased from 90% (95% CI, 89%-91%) after the first PICU-CIE to 81% (95% CI, 77%-86%) after the fourth PICU-CIE. Conclusions and Relevance This cohort study of children with SNI demonstrated a modest dose-dependent association between PICU-CIEs and short-term mortality. These data did not support the conventional wisdom that recurrent PICU admissions are associated with subsequent high mortality risk.
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Affiliation(s)
- Katherine E. Nelson
- Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jingqin Zhu
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Sanjay Mahant
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada
| | - Kimberley Widger
- Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Chris Feudtner
- The Justin Michael Ingerman Center for Palliative Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eyal Cohen
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - James A. Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children’s Hospital Colorado
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Uveges MK, Hamilton JB, Pados BF, Thayer WM, Hinds PS, Nolan MT. Being a "Good Parent" to a NICU Infant With a Major Congenital Anomaly. Adv Neonatal Care 2024; 24:14-26. [PMID: 38232327 DOI: 10.1097/anc.0000000000001127] [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: 01/19/2024]
Abstract
BACKGROUND In the United States, up to one-third of infants with a congenital anomaly require neonatal intensive care unit (NICU) hospitalization. Parents of these infants may have different decision-making priorities, which may be influenced by the timing of the infant's diagnosis. PURPOSE (1) To compare the ranked importance of decision-making beliefs for parents of infants who received a prenatal versus postnatal congenital diagnosis and (2) explore how parents describe their decision-making beliefs. METHODS A cross-sectional, sequential mixed-methods pilot design was applied to collect quantitative data using the Good Parent Ranking Exercise and further explore parents' decision-making beliefs through qualitative interviews. Maximum difference scaling/hierarchical Bayes estimation and content analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS Forty mothers completed the Good Parent Ranking Exercise and 20 mothers completed qualitative interviews. Four of the top 5 ranked parenting beliefs were shared by mothers in the prenatal and postnatal groups. Mothers in the postnatal group ranked "focusing on my child's quality of life" higher. Qualitative interviews revealed that previously identified decision-making beliefs were consistent in this NICU parent population, with 1 additional belief identified. Mixed-methods analysis revealed high concordance between the prenatal and postnatal groups. IMPLICATIONS FOR PRACTICE NICU nurses need to know that decision-making beliefs for parents who receive a prenatal versus postnatal congenital diagnosis, while largely similar, may have differences. IMPLICATIONS FOR RESEARCH Future research should explore decision-making beliefs in demographically diverse parent groups (ie, fathers, partnered vs nonpartnered couples) and effective strategies for promoting NICU parents' decision-making beliefs.
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Affiliation(s)
- Melissa K Uveges
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (Dr Uveges); Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia (Dr Hamilton); Infant Feeding Care, Wellesley Hills, Massachusetts (Dr Pados); School of Nursing, Johns Hopkins University, Baltimore, Maryland (Mr Thayer); Children's National Health System, Washington, District of Columbia (Dr Hinds); Department of Pediatrics, The George Washington University, Washington, District of Columbia (Dr Hinds); and Conway School of Nursing, The Catholic University of America, Washington, District of Columbia (Dr Nolan)
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4
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Tager JB, Hinojosa JT, LiaBraaten BM, Balistreri KA, Aniciete D, Charleston E, Frader JE, White DB, Clayman ML, Sorce LR, Davies WH, Rothschild CB, Michelson KN. Challenges of Families of Patients Hospitalized in the PICU: A Preplanned Secondary Analysis From the Navigate Dataset. Pediatr Crit Care Med 2024; 25:128-138. [PMID: 37889100 PMCID: PMC10840810 DOI: 10.1097/pcc.0000000000003385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
OBJECTIVES To describe challenges experienced by parents of children hospitalized in the PICU during PICU admission as reported by family navigators. DESIGN A preplanned secondary analysis of open-response data coded via inductive qualitative approach from the Navigate randomized controlled trial (RCT) dataset (ID NCT02333396). SETTING Two university-affiliated PICUs in the Midwestern United States as part of an RCT. PATIENTS Two hundred twenty-four parents of 190 PICU patients. INTERVENTIONS In 2015-2017, trained family navigators assessed and addressed parent needs, offered weekly family meetings, and provided post-PICU discharge parent check-ins as part of a study investigating the effectiveness of a communication support intervention ("PICU Supports"). MEASUREMENTS AND MAIN RESULTS We analyzed qualitative data recorded by family navigators weekly across 338 encounters. Navigators described families' "biggest challenge," "communication challenges," and ways the team could better support the family. We used an inductive qualitative coding approach and a modified member-checking exercise. The most common difficulties included home life , hospitalization , and diagnosis distress (45.2%, 29.0%, and 17.2% of families, respectively). Navigators often identified that parents had co-occurring challenges. Communication was identified as a "biggest challenge" for 8% of families. Communication challenges included lack of information, team communication , and communication quality (7.0%, 4.8%, and 4.8% of families, respectively). Suggestions for improving care included better medical communication, listening, rapport, and resources. CONCLUSIONS This study describes families' experiences and challenges assessed throughout the PICU stay. Family navigators reported families frequently experience stressors both internal and external to the hospital environment, and communication challenges between families and providers may be additional sources of distress. Further research should develop and assess interventions aimed at improving provider-family communication and reducing stressors outside the hospitalization itself, such as home life difficulties.
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Affiliation(s)
- Julia B Tager
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI
| | - Jessica T Hinojosa
- Department of Psychology, Southern Illinois University-Carbondale, Carbondale, IL
| | - Brynn M LiaBraaten
- Department of Anesthesiology, Medical College of Wisconsin & Jane B. Pettit Pain and Headache Center, Children's Wisconsin, Milwaukee, WI
| | | | | | - Elizabeth Charleston
- Department of Psychology, DePaul University, Chicago, IL
- Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Joel E Frader
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Douglas B White
- Program on Ethics and Decision Making in Critical Illness, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Marla L Clayman
- Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, Bedford, MA
- Department of Population and Quantitative Health Sciences, UMass Chan School of Medicine, Worcester, MA
| | - Lauren R Sorce
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - W Hobart Davies
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WI
| | - Charles B Rothschild
- Division of Critical Care Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Kelly N Michelson
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
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5
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Duval C, Porcheret F, Toulouse J, Alexandre M, Roulland C, Viallard ML, Brossier D. Withholding life support for children with severe neurological impairment: Prevalence and predictive factors prior to admission in the PICU. Arch Pediatr 2024; 31:66-71. [PMID: 37989656 DOI: 10.1016/j.arcped.2023.09.014] [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: 12/29/2022] [Revised: 05/17/2023] [Accepted: 09/30/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Our study aimed to evaluate the prevalence and predictive factors of withholding life support for children suffering from severe neurological impairment before admission to the pediatric intensive care unit (PICU). METHOD Children under 18 years of age with severe neurological impairment, who were hospitalized between January 2006 and December 2016, were included in this retrospective study. They were allocated to a withholding group or a control group, depending on whether life support was withheld or not, before admission to the PICU. RESULTS Overall, 119 patients were included. At admission to the PICU, the rate of withholding life support was 10 % (n = 12). Predictive factors were: (1) a previous stay in the PICU (n = 11; 92 %, p<0.01, odds ratio [OR]: 14 [2-635], p = 0.001); (2) the need for respiratory support (n = 5; 42 %, p = 0.01, OR: 6 [1-27], p = 0.01); (3) the need for feeding support (n = 10; 83 %, p = 0.01, OR: 10 [2-100], p = 0.001); and (4) a higher functional status score (FSS: 16 [12.5-19] vs. 10 [8-13], p<0.01). CONCLUSION The withholding of life support for children suffering from severe neurological impairment appeared limited in our pediatric department. The main predictor was at least one admission to the PICU, which raised the question of the pediatrician's role in the decision to withhold life support.
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Affiliation(s)
- Christophe Duval
- CH Monod, Neonatal Intensive Care Unit, Le Havre, F-76620, France
| | | | - Joseph Toulouse
- CHU de Lyon, Pediatric Neurology Unit, Bron, F-69677, France
| | | | | | - Marcel-Louis Viallard
- Necker Children's University, Neonate & Pediatric Palliative Medicine Team, Paris, F-75015, France
| | - David Brossier
- CHU de Caen, Pediatric Intensive Care Unit, Caen, F-14000, France; CHU de Caen, Pediatric department, Caen, F-14000, France; Université Caen Normandie, medical school, Caen, F-14000, France; Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France.
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6
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Prins S, Linn AJ, van Kaam AHLC, van de Loo M, van Woensel JBM, van Heerde M, Dijk PH, Kneyber MCJ, de Hoog M, Simons SHP, Akkermans AA, Smets EMA, de Vos MA. Diversity of Parent Emotions and Physician Responses During End-of-Life Conversations. Pediatrics 2023; 152:e2022061050. [PMID: 37575087 DOI: 10.1542/peds.2022-061050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To provide support to parents of critically ill children, it is important that physicians adequately respond to parents' emotions. In this study, we investigated emotions expressed by parents, physicians' responses to these expressions, and parents' emotions after the physicians' responses in conversations in which crucial decisions regarding the child's life-sustaining treatment had to be made. METHODS Forty-nine audio-recorded conversations between parents of 12 critically ill children and physicians working in the neonatal and pediatric intensive care units of 3 Dutch university medical centers were coded and analyzed by using a qualitative inductive approach. RESULTS Forty-six physicians and 22 parents of 12 children participated. In all 49 conversations, parents expressed a broad range of emotions, often intertwining, including anxiety, anger, devotion, grief, relief, hope, and guilt. Both implicit and explicit expressions of anxiety were prevalent. Physicians predominantly responded to parental emotions with cognition-oriented approaches, thereby limiting opportunities for parents. This appeared to intensify parents' expressions of anger and protectiveness, although their anxiety remained under the surface. In response to more tangible emotional expressions, for instance, grief when the child's death was imminent, physicians provided parents helpful support in both affect- and cognition-oriented ways. CONCLUSIONS Our findings illustrate the diversity of emotions expressed by parents during end-of-life conversations. Moreover, they offer insight into the more and less helpful ways in which physicians may respond to these emotions. More training is needed to help physicians in recognizing parents' emotions, particularly implicit expressions of anxiety, and to choose helpful combinations of responses.
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Affiliation(s)
- Sanne Prins
- Department of Pediatrics, Emma Children's Hospital
| | - Annemiek J Linn
- Amsterdam School of Communication Research, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Moniek van de Loo
- Department of Pediatrics, Division of Neonatology, Emma Children's Hospital
| | - Job B M van Woensel
- Department of Pediatrics, Division of Pediatric Intensive Care, Emma Children's Hospital
| | - Marc van Heerde
- Department of Pediatrics, Division of Pediatric Intensive Care, Emma Children's Hospital
| | | | - Martin C J Kneyber
- Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Sinno H P Simons
- Neonatology, Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Aranka A Akkermans
- Department of Medical Psychology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Rholl E, Leuthner SR. The logistics of withdrawing life-sustaining medical treatment in the neonatal intensive care unit. Semin Fetal Neonatal Med 2023; 28:101443. [PMID: 37596126 DOI: 10.1016/j.siny.2023.101443] [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: 08/20/2023]
Abstract
Withdrawal of life sustaining medical treatments is a common mode of death in the neonatal intensive care unit. Shared decision making and communication are crucial steps prior to, during and after a withdrawal of life sustaining medical treatments. Discussion should include the steps to occur during the withdrawal. Physicians should recommend appropriate withdrawal steps based on family goals. Stepwise approach should be taken only if a family requests. Care should continue for the family and staff after the withdrawal and the infant's death.
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Affiliation(s)
- Erin Rholl
- Department of Pediatrics, Medical College of Wisconsin, 999 N 92nd St, Suite C 410, Wauwatosa, Wisconsin, 53226, USA.
| | - Steven R Leuthner
- Department of Pediatrics, Medical College of Wisconsin, 999 N 92nd St, Suite C 410, Wauwatosa, Wisconsin, 53226, USA.
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8
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Friedrich AB. Ethical Consequences of Technological Mediation on Parental Decision-Making Experiences in the Neonatal Intensive Care Unit. QUALITATIVE HEALTH RESEARCH 2023; 33:259-269. [PMID: 36704925 DOI: 10.1177/10497323231151816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The neonatal intensive care unit (NICU) is a morally charged space in which parents may be confronted with difficult decisions about the treatment of their newborns, decisions often complicated and created by the increasing use of technologies. This paper adopts a postphenomenological approach to explore the ethical consequences of technological mediation on parental treatment decision-making in the NICU. Semi-structured interviews were conducted with parents of children who received invasive technological support in the NICU to better understand how they made treatment decisions or decisions about specific interventions during their child's hospitalization. The findings suggest that technological mediation-or the various ways in which humans can interact with their world via technologies-contributes to experiences of ambiguity, ambivalence, and alienation in parental decision-making. The ambiguity of invasive NICU technologies can create uncertainty in a decision, which can then lead to internal ambivalence about which decision to make. Ultimately, this ambiguity and ambivalence may lead to alienation from one's child, as parents are disconnected physically and emotionally from the decision and thus their child. Articulating the effects of technological mediation on parental decision-making is a key step in addressing decisional conflict in neonatal intensive care settings and better supporting parents in their decision-making roles.
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Affiliation(s)
- Annie B Friedrich
- Center for Bioethics and Medical Humanities, Institute for Health & Equity, 5506Medical College of Wisconsin, Milwaukee, WI, USA
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9
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Abdin S, Heath G, Neilson S, Byron‐Daniel J, Hooper N. Decision-making experiences of health professionals in withdrawing treatment for children and young people: A qualitative study. Child Care Health Dev 2022; 48:531-543. [PMID: 34994015 PMCID: PMC9306775 DOI: 10.1111/cch.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/20/2021] [Accepted: 12/31/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore factors that influence professionals in deciding whether to withdraw treatment from a child and how decision making is managed amongst professionals as an individual and as a team. STUDY DESIGN Semi-structured interviews were conducted with a purposive sample of health professionals working at a UK Children's Hospital, with children with life-limiting illnesses whose treatment has been withdrawn. Data were transcribed verbatim, anonymized and analysed using a thematic framework method. RESULTS A total of 15 participants were interviewed. Five interrelated themes with associated subthemes were generated to help understand the experiences of health professionals in decision making on withdrawing a child's treatment: (1) understanding the child's best interests, (2) multidisciplinary approach, (3) external factors, (4) psychological well-being and (5) recommendations to support shared decision making. CONCLUSION A shared decision-making approach should be adopted to support professionals, children and their families to make decisions collectively.
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Affiliation(s)
- Shanara Abdin
- Faculty of Health and Applied SciencesUniversity of the West of EnglandBristolUK
- Public Health and WellbeingCity of Wolverhampton CouncilWolverhamptonUK
| | - Gemma Heath
- School of PsychologyAston UniversityBirminghamUK
| | - Susan Neilson
- School of NursingUniversity of BirminghamBirminghamUK
| | - James Byron‐Daniel
- Faculty of Health and Applied SciencesUniversity of the West of EnglandBristolUK
| | - Nic Hooper
- School of PsychologyCardiff UniversityCardiffUK
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10
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Broden EG, Werner-Lin A, Curley MAQ, Hinds PS. 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. [PMID: 35219558 PMCID: PMC9128001 DOI: 10.1016/j.iccn.2022.103216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To examine parents' perceptions of nursing care needs; including specific concerns, preferences and supportive actions for themselves and their dying child during and following the withdrawal of life support in the paediatric intensive care unit. RESEARCH DESIGN Qualitative description with content analysis. SETTING Interviews with eight parents of eight children who died in the paediatric intensive care unit 7-11 years prior. MAIN OUTCOME MEASURES Descriptive categories of parents' perceptions of end-of-life needs. FINDINGS Parents identified four shifting and intersecting categories of needs: To be together, To make sense of the child's evolving clinical care, To manage institutional, situational, and structural factors, and To navigate an array of emotions in a sterile context. Being closely connected with the child was highly important, but often intersected with other domains, requiring nurses' support. Parents' memories demonstrated persistent uncertainty about their child's end-of-life care that influenced their long-term grief. CONCLUSIONS Intersections between parent-identified care needs suggest potential mechanisms to strengthen nurses' care for dying children. Equipped with the knowledge that the parent-child bond often shapes parents' priorities; nurses should aim to facilitate connections amidst paediatric intensive care unit processes. Ongoing uncertainty in parents' adaptation to loss suggests that attention to instances when needs intersect can have a lasting impact on parents' grief.
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Affiliation(s)
- Elizabeth G Broden
- Psychosocial Oncology & Palliative Care, Dana-Farber Cancer Institute, 375 Longwood Ave, Boston, MA 02215, United States; University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States.
| | - Allison Werner-Lin
- University of Pennsylvania School of Social Policy and Practice, 3701 Locust Walk, Philadelphia, PA 19104, United States; National Cancer Institute, National Institutes of Health, 31 Center Drive, Bethesda, MD 20814, United States
| | - Martha A Q Curley
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States; University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States; Anesthesia and Critical Care Medicine University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Pamela S Hinds
- Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, United States; George Washington University, 2121 I St NW, Washington, DC 20052, United States
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Bogetz JF, Trowbridge A, Lewis H, Jonas D, Hauer J, Rosenberg AR. Forming Clinician-Parent Therapeutic Alliance for Children With Severe Neurologic Impairment. Hosp Pediatr 2022; 12:282-292. [PMID: 35141756 DOI: 10.1542/hpeds.2021-006316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Care for children with severe neurologic impairment (SNI) often involves complex medical decision-making where therapeutic alliance between clinicians and families is essential. Yet, existing data suggest that communication and alliance are often lacking. This study aimed to examine aspects important to developing therapeutic alliance between clinicians and parents of children with SNI. METHODS A purposive sample of expert clinicians and parents of children with SNI completed brief demographic surveys and 1:1 semistructured interviews between July 2019 and August 2020 at a single tertiary pediatric academic center. Interviews focused on the inpatient experience and transcriptions underwent thematic analysis by a study team of qualitative researchers with expertise in palliative care and communication science. RESULTS Twenty-five parents and 25 clinicians participated (total n = 50). Many parents were mothers (n = 17, 68%) of school-aged children with congenital/chromosomal conditions (n = 15, 65%). Clinicians represented 8 professions and 15 specialties. Responses from participants suggested 3 major themes that build and sustain therapeutic alliance including: (1) foundational factors that must exist to establish rapport; (2) structural factors that provide awareness of the parent/child experience; and (3) weathering factors that comprise the protection, security, and additional support during hard or uncertain times. Participants also shared concrete actions that promote these factors in clinical practice. CONCLUSION Therapeutic alliance between clinicians and parents of children with SNI consists of at least 3 factors that support communication and medical decision-making. These factors are facilitated by concrete actions and practices, which enhance communication about the care for children with SNI.
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Affiliation(s)
- Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research
- Palliative Care Resilience Research Laboratory, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Amy Trowbridge
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research
- Palliative Care Resilience Research Laboratory, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Hannah Lewis
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research
| | - Danielle Jonas
- Silver School of Social Work, New York University, New York, New York
| | - Julie Hauer
- Seven Hills Pediatric Center, Groton, Massachusetts
| | - Abby R Rosenberg
- Palliative Care Resilience Research Laboratory, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
- Division of Hematology Oncology, Department of Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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12
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Personalized communication with parents of children born at less than 25 weeks: Moving from doctor-driven to parent-personalized discussions. Semin Perinatol 2022; 46:151551. [PMID: 34893335 DOI: 10.1016/j.semperi.2021.151551] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Communication with parents is an essential component of neonatal care. For extremely preterm infants born at less than 25 weeks, this process is complicated by the substantial risk of mortality or major morbidity. For some babies with specific prognostic factors, the majority die. Although many of these deaths occur after admission to the intensive care unit, position statements have focused on communication during the prenatal consultation. This review takes a more comprehensive approach and covers personalized and parent-centered communication in the clinical setting during three distinct yet inter-related phases: the antenatal consultation, the neonatal intensive care hospitalization, and the dying process (when this happens). We advocate that a 'one-size-fits-all' communication model focused on standardizing information does not lead to partnerships. It is possible to standardize personalized approaches that recognize and adapt to parental heterogeneity. This can help clinicians and parents build effective partnerships of trust and affective support to engage in personalized decision-making. These practices begin with self-reflection on the part of the clinician and continue with practical frameworks and stepwise approaches supporting personalization and parent-centered communication.
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13
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Kruithof K, Olsman E, Nieuwenhuijse A, Willems D. Parents' views on medical decisions related to life and death for their ageing child with profound intellectual and multiple disabilities: A qualitative study. RESEARCH IN DEVELOPMENTAL DISABILITIES 2022; 121:104154. [PMID: 34954670 DOI: 10.1016/j.ridd.2021.104154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND The increased life expectancy of persons with profound intellectual and multiple disabilities (PIMD) raises questions regarding the medical decisions related to life and death, made on their behalf during their later lives. However, little is known about how parents make such decisions for their ageing child. AIM Explore parents' views on medical decisions related to life and death for their ageing child with PIMD. METHODS We interviewed 27 parents of persons with PIMD (≥ 15 years) and analyzed the data thematically. RESULTS Parents who were convinced that their ageing child's quality of life (QoL) was good, stated that their child "deserved the same treatment as any other person". Others rejected life-prolonging treatments for their child because they believed such treatment would diminish their child's QoL. Some of the parents who thought their child's QoL was poor, mentioned that withholding treatment is only an option in a crisis situation and contemplated other options to shorten their child's life. CONCLUSIONS Parents feel equipped to take on a central role in medical decisions related to life and death for their ageing child with PIMD, and desire understanding from medical professionals for their views on their child's interests, which sometimes includes physician-assisted death.
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Affiliation(s)
- Kasper Kruithof
- Department of Ethics, Law & Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Erik Olsman
- Department of Mediating Good Life, Section of Spiritual Care & Chaplaincy Studies, Protestant Theological University, Groningen, the Netherlands
| | - Appolonia Nieuwenhuijse
- Department of Ethics, Law & Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Dick Willems
- Department of Ethics, Law & Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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14
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Daxer M, Monz A, Hein K, Heitkamp N, Knochel K, Borasio GD, Führer M. How to Open the Door: A Qualitative, Observational Study on Initiating Advance Care Discussions with Parents in Pediatric Palliative Care. J Palliat Med 2021; 25:562-569. [PMID: 34807732 DOI: 10.1089/jpm.2021.0183] [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: 11/13/2022] Open
Abstract
Context: Advance care discussions (ACD) between health care professionals (HCPs) and parents of children with a life-limiting disease are a core element of successful pediatric advance care planning (pACP). Yet, they are perceived as a challenging situation for all participants. Objectives: Our goal was to investigate the first step of ACD and identify its challenges and helpful communication strategies to develop a conversation guide for initiating the pACP process and structure the conversational opening. Methods: We performed a participant observation of 11 initial ACD and 24 interviews with 13 HCPs and 20 parents of 11 children cared for by 3 different palliative care teams in southern Germany. Qualitative data collection was supplemented by a questionnaire. Content analysis and conversation analysis were used for evaluation. Results: Parents and HCPs start the process with different expectations, which can lead to misunderstandings and confusion. HCPs gain parental cooperation when they express the purpose of the meeting clearly and early, provide structure and guidance, and give parents time to talk about their experiences and feelings. Addressing dying and death is hard for both sides and requires a sensitive approach. Conclusions: Initiating ACD is extremely challenging for all participants. HCPs and parents should clarify expectations and aims at the beginning of the conversation. Future research should focus on how HCPs can be trained for this task and how the right timing for introducing ACD to families can be identified. Clinical Trial Registration number 049-12.
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Affiliation(s)
- Marion Daxer
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Anna Monz
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Kerstin Hein
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Nari Heitkamp
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Kathrin Knochel
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
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15
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Vig PS, Lim JY, Lee RWL, Huang H, Tan XH, Lim WQ, Lim MBXY, Lee ASI, Chiam M, Lim C, Baral VR, Krishna LKR. Parental bereavement - impact of death of neonates and children under 12 years on personhood of parents: a systematic scoping review. BMC Palliat Care 2021; 20:136. [PMID: 34481491 PMCID: PMC8418708 DOI: 10.1186/s12904-021-00831-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Losing a child tragically impacts the well-being and functioning of parents. With these effects extending beyond emotional, physical morbidity and compromising self-perceptions, appropriate, longitudinal, timely and personalised support is key to effective care of bereaved parents. However, in the absence of a comprehensive understanding of parental bereavement, effective support of bereaved parents remains suboptimal. To address this gap, we scrutinise prevailing data on the effects of a child's death, aged 0-12 years, through the lens of the Ring Theory of Personhood (RToP). METHODS To study prevailing accounts of bereaved parents following the death of a child, we adopt Krishna's Systematic Evidence Based Approach (SEBA) to structure our Systematic Scoping Review (SSR in SEBA). RESULTS Three thousand seventy-four abstracts were reviewed, 160 full text articles were evaluated, and 111 articles were included and analysed using thematic and content analysis. Four themes/categories were identified relating to the four rings of the RToP. Findings reveal that static concepts of protective and risk factors for grief are misplaced and that the support of healthcare professionals is key to assisting bereaved parents. CONCLUSION In the absence of consistent support of bereaved parents, this study highlights the need for effective training of healthcare professionals, beginning with an appreciation that every aspect of an individual parent's personhood is impacted by the loss of their child. Acknowledging grief as a complex, evolving and personalised process subjected to parental characteristics, settings, context and available support, this SSR in SEBA calls attention to effective nurturing of the relationship between parents and healthcare professionals, and suggests use of the RToP to assess and direct personalised, timely, specific support of parents in evolving conditions. We believe the findings of this review also call for further studies to support healthcare professionals as they journey with bereaved parents.
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Affiliation(s)
- Prachi Simran Vig
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Jia Yin Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Randal Wei Liang Lee
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Huixin Huang
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Xiu Hui Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Wei Qiang Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Marie Bernadette Xin Yi Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Alexia Sze Inn Lee
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Crystal Lim
- Medical Social Services, Singapore General Hospital, Outram Road, Block 3 Level 1, Singapore, 169608 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
| | - Vijayendra Ranjan Baral
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Division of Neonatal and Developmental Medicine, Singapore General Hospital, Outram Road, Block 5 Level 4, Singapore, 169608 Singapore
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK
- Centre for Biomedical Ethics, National University of Singapore, Blk MD11, 10 Medical Drive, #02-03, Singapore, 117597 Singapore
- PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, 10 Jalan Tan Tock Seng, Singapore, 308436 Singapore
- Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool, L3 9TA UK
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16
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McDonnell S, Yan K, Kim UO, Flynn KE, Liegl MN, Leuthner SR, McIntosh JJ, Basir MA. Information Order for Periviable Counseling: Does It Make a Difference? J Pediatr 2021; 235:100-106.e1. [PMID: 33811868 PMCID: PMC8316277 DOI: 10.1016/j.jpeds.2021.03.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/15/2021] [Accepted: 03/26/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To examine whether the order of presenting survival vs disability information, with or without the description of infant neonatal intensive care unit (NICU) experiences would influence treatment choice during hypothetical periviable birth counseling. STUDY DESIGN An internet sample of childbearing-aged women (n = 839) viewed a pictograph displaying the chances of survival and a pictograph on the chances of disability for a baby resuscitated during the periviable period. The sample was randomized to the order of pictographs and level of description of infant NICU experiences. Participants selected between intensive care or comfort care and reported their personal values. RESULTS The order of the information influenced treatment choices (P = .02); participants were more likely to choose intensive care if they saw the survival pictograph first (70%) than the disability pictograph first (62%). Level of description of premature infant NICU experiences did not influence treatment choice (P = .92). Participants who valued sanctity of life, autonomy in making decisions, who were more religious, and had adequate health literacy were more likely to choose intensive care. Such participant characteristics had greater explanatory power than the experimental manipulations. CONCLUSIONS Subtle differences in how information is presented may influence critical decisions. However, even among women with the same values, diversity in treatment choice remains.
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Affiliation(s)
- Siobhan McDonnell
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI
| | - Ke Yan
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - U Olivia Kim
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI
| | - Kathryn E Flynn
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Melodee Nugent Liegl
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Steven R Leuthner
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI; Department of Population Health, Center for the Study of Bioethics, Medical College of Wisconsin, Milwaukee, WI
| | - Jennifer J McIntosh
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mir A Basir
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI.
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17
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End-of-life decision making in critical illness: Perspectives of Asian parents. Palliat Support Care 2021; 20:233-242. [PMID: 33942708 DOI: 10.1017/s1478951521000493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To explore parents' perspectives regarding end-of-life (EOL) decisions, factors and possible barriers that influence the EOL decision making process, and to understand parental preferences for communication about EOL care in an Asian population. METHOD A prospective questionnaire cohort study conducted in a university-based tertiary care hospital. 30 parents of children who had been admitted to general pediatric wards for acute ailments and/or were being followed up in general pediatric outpatient clinics after inpatient admissions or emergency department visits completed 30 interviewer-administered questionnaires. With the first 10 completed questionnaires, we sought feedback on the design of the four case vignettes and related questions. Responses to specific questions related to each case vignette were rated on a Likert scale. RESULTS The majority of parents were able to comprehend and identify with the issues in the case vignettes, which allowed them to respond appropriately. Parents tended to avoid active withdrawal or withholding of life-sustaining treatment. The top three priorities for parents making EOL decisions for their children were: the chance of improvement, the presence of pain or discomfort, and information provided by healthcare staff. Parents reported that they would prefer to know immediately if their child is at risk of dying; they also preferred to get as much information as possible from the healthcare team and thought that meeting with the healthcare team before making EOL decisions was pivotal. SIGNIFICANCE OF RESULTS Parents place highest priorities on their child's likelihood of improvement, perception of their child's pain, and information provided by healthcare professionals in making EOL decisions.
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18
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Cremer R, de Saint Blanquat L, Birsan S, Bordet F, Botte A, Brissaud O, Guilbert J, Le Roux B, Le Reun C, Michel F, Millasseau F, Sinet M, Hubert P. Withholding and withdrawing treatment in pediatric intensive care. Update of the GFRUP recommendations. Arch Pediatr 2021; 28:325-337. [PMID: 33875345 DOI: 10.1016/j.arcped.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/15/2021] [Indexed: 11/29/2022]
Abstract
In 2005, the French-speaking task force on pediatric critical and emergency care [Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws.
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Affiliation(s)
- R Cremer
- Réanimation et soins continus pédiatriques, hôpital Jeanne-de-Flandre, ERER des Hauts-de-France, CHU de Lille, 59037 Lille, France.
| | - L de Saint Blanquat
- Réanimation pédiatrique, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France
| | - S Birsan
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - F Bordet
- Réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69500 Lyon-Bron, France
| | - A Botte
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - O Brissaud
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - J Guilbert
- Réanimation néonatale pédiatrique, hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - B Le Roux
- Réanimation pédiatrique, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - C Le Reun
- Réanimation pédiatrique, hôpital Clocheville, CHU de Tours, 2, boulevard Tonnelle, 37000 Tours, France
| | - F Michel
- Anesthésie et réanimation pédiatrique, hôpital de la Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - F Millasseau
- Réanimation pédiatrique, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - M Sinet
- Réanimation néonatale pédiatrique, hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Réanimation et surveillance continue pédiatriques, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France
| | - P Hubert
- Réanimation pédiatrique, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France
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McCauley KE, Carey EC, Weaver AL, Mara KC, Clark RH, Carey WA, Collura CA. Survival of Ventilated Extremely Premature Neonates With Severe Intraventricular Hemorrhage. Pediatrics 2021; 147:e20201584. [PMID: 33727247 PMCID: PMC8015160 DOI: 10.1542/peds.2020-1584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Severe intraventricular hemorrhage (IVH) is a leading mortality risk factor among extremely premature neonates. Because other life-threatening conditions also occur in this population, it is unclear whether severe IVH is independently associated with death. The existence and potential implications of regional variation in severe IVH-associated mortality are unknown. METHODS We performed a retrospective cohort study of mechanically ventilated neonates born at 22 to 29 weeks' gestation who received care in 242 American NICUs between 2000 and 2014. After building groups composed of propensity score-matched and center-matched pairs, we used the Cox proportional hazards analysis to test our hypothesis that severe IVH would be associated with greater all-cause in-hospital mortality, defined as death before transfer or discharge. We also performed propensity score-matched subgroup analyses, comparing severe IVH-associated mortality among 4 geographic regions of the United States. RESULTS In our analysis cohort, we identified 4679 patients with severe IVH. Among 2848 matched pairs, those with severe IVH were more likely to die compared with those without severe IVH (hazard ratio 2.79; 95% confidence interval 2.49-3.11). Among 1527 matched pairs still hospitalized at 30 days, severe IVH was associated with greater risk of death (hazard ratio 2.03; 95% confidence interval 1.47-2.80). Mortality associated with severe IVH varied substantially between geographic regions. CONCLUSIONS The early diagnosis of severe IVH is independently associated with all-cause in-hospital mortality in extremely premature neonates. Regional variation in severe IVH-associated mortality suggests that shared decision-making between parents and neonatologists is strongly influenced by ultrasound-based IVH assessment and classification.
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Affiliation(s)
| | | | - Amy L Weaver
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Kristin C Mara
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Reese H Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
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20
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Lin SC, Huang MC. Consulting with a folk deity before making decisions: spiritual practices in parents facing end-of-life decisions for their child on life support with brain stem dysfunction. Int J Qual Stud Health Well-being 2021; 15:1756686. [PMID: 32340564 PMCID: PMC7241511 DOI: 10.1080/17482631.2020.1756686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Adolescents with brain stem dysfunction may undergo many invasive treatments, and parents are often faced with making the decision to withdraw treatment. However, in the face of their child’s death, the spiritual practices of parents dealing with end-of-life decision-making remain under investigated. Purpose This study explores the spiritual practices in parents making end-of-life decisions for adolescents on life support with brain stem dysfunction. Method A descriptive phenomenological study was conducted through in-depth interviews with three parents of two adolescents in Taiwan. Data were analysed using Colaizzi’s seven-step protocol. Results Three main themes emerged: (1) faith during decision-making, (2) struggles during decision-making, (3) transformation during decision-making. The findings indicate that “transforming the nature of hope” is the essence of the experience. Conclusion Family-centred care, gaining insight into parental spiritual practices, and developing culturally-appropriate care are recommended.
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Affiliation(s)
- Shih-Chun Lin
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mei-Chih Huang
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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21
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Boyden JY, Ersek M, Deatrick JA, Widger K, LaRagione G, Lord B, Feudtner C. What Do Parents Value Regarding Pediatric Palliative and Hospice Care in the Home Setting? J Pain Symptom Manage 2021; 61:12-23. [PMID: 32745574 PMCID: PMC9747513 DOI: 10.1016/j.jpainsymman.2020.07.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 12/16/2022]
Abstract
CONTEXT Children with life-shortening serious illnesses and medically-complex care needs are often cared for by their families at home. Little, however, is known about what aspects of pediatric palliative and hospice care in the home setting (PPHC@Home) families value the most. OBJECTIVES To explore how parents rate and prioritize domains of PPHC@Home as the first phase of a larger study that developed a parent-reported measure of experiences with PPHC@Home. METHODS Twenty domains of high-value PPHC@Home, derived from the National Consensus Project's Guidelines for Quality Palliative Care, the literature, and a stakeholder panel, were evaluated. Using a discrete choice experiment, parents provided their ratings of the most and least valued PPHC@Home domains. We also explored potential differences in how subgroups of parents rated the domains. RESULTS Forty-seven parents participated. Overall, highest-rated domains included Physical aspects of care: Symptom management, Psychological/emotional aspects of care for the child, and Care coordination. Lowest-rated domains included Spiritual and religious aspects of care and Cultural aspects of care. In exploratory analyses, parents who had other children rated the Psychological/emotional aspects of care for the sibling(s) domain significantly higher than parents who did not have other children (P = 0.02). Furthermore, bereaved parents rated the Caregiversupportat the end of life domain significantly higher than parents who were currently caring for their child (P = 0.04). No other significant differences in domain ratings were observed. CONCLUSION Knowing what parents value most about PPHC@Home provides the foundation for further exploration and conversation about priority areas for resource allocation and care improvement efforts.
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Affiliation(s)
- Jackelyn Y Boyden
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Mary Ersek
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Janet A Deatrick
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gwenn LaRagione
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Blyth Lord
- Courageous Parents Network, Newton, MA, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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22
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Katz NT, Sacks BH, Hynson JL, Heywood M, Williams M, Sokol J. Improving paediatric advance care planning: Results of a learning needs analysis and simulation-based education programme. J Paediatr Child Health 2020; 56:1898-1905. [PMID: 32812306 DOI: 10.1111/jpc.15074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 11/28/2022]
Abstract
AIM To assess clinicians' experience, attitudes and confidence with advance care planning (ACP) at a quaternary paediatric referral centre using a learning-needs survey, and then apply this information to develop and examine the feasibility of simulation-based education for this topic. METHODS An electronic learning-needs survey was distributed to medical, nursing and allied health clinicians from departments who provide primary care for children with life-limiting conditions. Results were incorporated into the design of a simulation-based education session which was piloted with the Royal Children's Hospital Oncology Department. RESULTS A total of 157 learning-needs surveys were included in analysis, and included quantitative and qualitative responses from nursing, allied health, senior and junior medical staff from intensive care, general and subspecialty medical teams. Most (75.0%) participants had participated in ACP discussions previously. Only 40.1% of participants felt confident to assess appropriate timing of, and 45.2% felt adequately prepared to participate in ACP discussions. Barriers identified were both clinician and patient/parent related, including clinicians not knowing when to address issues (43.9%) or what to say (21.0%). Participants indicated that ACP discussions are most frequently initiated when death is clearly imminent. Following a pilot of simulation-based education with the oncology department, 90% of participants expressed confidence to participate in ACP discussions. CONCLUSIONS Barriers to paediatric ACP, including lack of clinician training, continue to contribute to delayed conversations. Simulation-based education is a valuable and feasible educational tool that can increase clinicians' understanding and confidence in this area.
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Affiliation(s)
- Naomi T Katz
- Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Melbourne, Victoria, Australia.,Simulation Program, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Paediatrics Group, Murdoch Children's Research Group, Melbourne, Victoria, Australia
| | - Bronwyn H Sacks
- Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Jenny L Hynson
- Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Paediatrics Group, Murdoch Children's Research Group, Melbourne, Victoria, Australia
| | - Melissa Heywood
- Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Melbourne, Victoria, Australia.,Simulation Program, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Molly Williams
- Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Jenni Sokol
- Simulation Program, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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23
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A Randomized Comparative Trial to Evaluate a PICU Navigator-Based Parent Support Intervention. Pediatr Crit Care Med 2020; 21:e617-e627. [PMID: 32639470 DOI: 10.1097/pcc.0000000000002378] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Communication breakdowns in PICUs contribute to inadequate parent support and poor post-PICU parent outcomes. No interventions supporting communication have demonstrated improvements in parental satisfaction or psychologic morbidity. We compared parent-reported outcomes from parents receiving a navigator-based parent support intervention (PICU Supports) with those from parents receiving an informational brochure. DESIGN Patient-level, randomized trial. SETTING Two university-based, tertiary-care children's hospital PICUs. PARTICIPANTS Parents of patients requiring more than 24 hours in the PICU. INTERVENTIONS PICU Supports included adding a trained navigator to the patient's healthcare team. Trained navigators met with parents and team members to assess and address communication, decision-making, emotional, informational, and discharge or end-of-life care needs; offered weekly family meetings; and did a post-PICU discharge parent check-in. The comparator arm received an informational brochure providing information about PICU procedures, terms, and healthcare providers. MEASUREMENTS AND MAIN RESULTS The primary outcome was percentage of "excellent" responses to the Pediatric Family Satisfaction in the ICU 24 decision-making domain obtained 3-5 weeks following PICU discharge. Secondary outcomes included parental psychologic and physical morbidity and perceptions of team communication. We enrolled 382 families: 190 received PICU Supports, and 192 received the brochure. Fifty-seven percent (216/382) completed the 3-5 weeks post-PICU discharge survey. The mean percentage of excellent responses to the Pediatric Family Satisfaction in the ICU 24 decision-making items was 60.4% for PICU Supports versus 56.1% for the brochure (estimate, 3.57; SE, 4.53; 95% CI, -5.77 to 12.90; p = 0.44). Differences in secondary outcomes were not statistically significant. Most parents (91.1%; 113/124) described PICU Supports as "extremely" or "somewhat" helpful. CONCLUSIONS Parents who received PICU Supports rated the intervention positively. Differences in decision-making satisfaction scores between those receiving PICU Supports and a brochure were not statistically significant. Interventions like PICU Supports should be evaluated in larger studies employing enhanced recruitment and retention of subjects.
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24
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Michelson KN, Charleston E, Aniciete DY, Sorce LR, Fragen P, Persell SD, Ciolino JD, Clayman ML, Rychlik K, Jones VA, Spadino P, Malakooti M, Brown M, White D. Navigator-Based Intervention to Support Communication in the Pediatric Intensive Care Unit: A Pilot Study. Am J Crit Care 2020; 29:271-282. [PMID: 32607571 DOI: 10.4037/ajcc2020478] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Communication in the pediatric intensive care unit (PICU) between families and the health care team affects the family experience, caregiver psychological morbidity, and patient outcomes. OBJECTIVE To test the feasibility of studying and implementing a PICU communication intervention called PICU Supports, and to assess families' and health care teams' perceptions of the intervention. METHODS This study involved patients requiring more than 24 hours of PICU care. An interventionist trained in PICU-focused health care navigation, a "navigator," met with parents and the health care team to discuss communication, decision-making, emotional, informational, and discharge or end-of-life care needs; offered weekly family meetings; and checked in with parents after PICU discharge. The feasibility of implementing the intervention was assessed by tracking navigator activities. Health care team and family perceptions were assessed using surveys, interviews, and focus groups. RESULTS Of 53 families approached about the study, 35 (66%) agreed to participate. The navigator met with parents on 71% and the health care team on 85% of possible weekdays, and completed 86% of the postdischarge check-ins. Family meetings were offered to 95% of eligible patients. The intervention was rated as helpful by 97% of parents, and comments during interviews were positive. CONCLUSIONS The PICU Supports intervention is feasible to implement and study and is viewed favorably by parents.
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Affiliation(s)
- Kelly N. Michelson
- About the Authors: Kelly N. Michelson is an attending physician, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, and a professor, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Elizabeth Charleston
- Elizabeth Charleston is lead clinical research coordinator, Danica Y. Aniciete is a clinical research coordinator/navigator, Virginia A. Jones is a clinical research associate, and Pamela Spadino is a parent of a medically complex child, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Danica Y. Aniciete
- Elizabeth Charleston is lead clinical research coordinator, Danica Y. Aniciete is a clinical research coordinator/navigator, Virginia A. Jones is a clinical research associate, and Pamela Spadino is a parent of a medically complex child, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Lauren R. Sorce
- Lauren R. Sorce is the Founders Board nurse scientist, Department of Nursing, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Feinberg School of Medicine, Northwestern University
| | | | - Stephen D. Persell
- Stephen D. Persell is an associate professor, Division of General Internal Medicine and Geriatrics, Department of Medicine, Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University
| | - Jody D. Ciolino
- Jody D. Ciolino is an associate professor, Division of Biostatistics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University
| | - Marla L. Clayman
- Marla L. Clayman is an adjunct faculty member at Northwestern University
| | - Karen Rychlik
- Karen Rychlik is a statistician, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, and an instructor, Feinberg School of Medicine, Northwestern University
| | - Virginia A. Jones
- Elizabeth Charleston is lead clinical research coordinator, Danica Y. Aniciete is a clinical research coordinator/navigator, Virginia A. Jones is a clinical research associate, and Pamela Spadino is a parent of a medically complex child, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Pamela Spadino
- Elizabeth Charleston is lead clinical research coordinator, Danica Y. Aniciete is a clinical research coordinator/navigator, Virginia A. Jones is a clinical research associate, and Pamela Spadino is a parent of a medically complex child, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Marcelo Malakooti
- Marcelo Malakooti is an atending physician and medical director, Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, and an assistant professor, Department of Pediatrics, Feinberg School of Medicine, Northwestern University
| | - Melanie Brown
- Melanie Brown is an associate professor of pediatric critical care medicine, Department of Pediatrics, University of Chicago Medicine Comer Children’s Hospital, Chicago, Illinois
| | - Douglas White
- Douglas White is director, Program in Ethics and Decision Making in Critical Illness, and vice chair, professor, and Endowed Chair for Ethics, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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25
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Greenfield K, Holley S, Schoth DE, Harrop E, Howard RF, Bayliss J, Brook L, Jassal SS, Johnson M, Wong I, Liossi C. A mixed-methods systematic review and meta-analysis of barriers and facilitators to paediatric symptom management at end of life. Palliat Med 2020; 34:689-707. [PMID: 32228216 PMCID: PMC7521017 DOI: 10.1177/0269216320907065] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Symptom management for infants, children and young people at end of life is complex and challenging due to the range of conditions and differing care needs of individuals of different ages. A greater understanding of these challenges could inform the development of effective interventions. AIM To investigate the barriers and facilitators experienced by patients, carers and healthcare professionals managing symptoms in infants, children and young people at end of life. DESIGN A mixed-methods systematic review and meta-analysis was undertaken (PROSPERO ID: CRD42019124797). DATA SOURCES The Cochrane Library, PROSPERO, CINAHL, MEDLINE, PsycINFO, Web of Science Core Collection, ProQuest Dissertations & Theses Database, Evidence Search and OpenGrey were electronically searched from the inception of each database for qualitative, quantitative or mixed-methods studies that included data from patients, carers or healthcare professionals referring to barriers or facilitators to paediatric end-of-life symptom management. Studies underwent data extraction, quality appraisal, narrative thematic synthesis and meta-analysis. RESULTS A total of 64 studies were included (32 quantitative, 18 qualitative and 14 mixed-methods) of medium-low quality. Themes were generated encompassing barriers/facilitators experienced by carers (treatment efficacy, treatment side effects, healthcare professionals' attitudes, hospice care, home care, families' symptom management strategies) and healthcare professionals (medicine access, treatment efficacy, healthcare professionals' demographics, treatment side effects, specialist support, healthcare professionals' training, health services delivery, home care). Only one study included patients' views. CONCLUSION There is a need for effective communication between healthcare professionals and families, more training for healthcare professionals, improved symptom management planning including anticipatory prescribing, and urgent attention paid to the patients' perspective.
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Affiliation(s)
- Katie Greenfield
- School of Psychology, University of Southampton, Southampton, UK
| | - Simone Holley
- School of Psychology, University of Southampton, Southampton, UK
| | - Daniel E Schoth
- School of Psychology, University of Southampton, Southampton, UK
| | - Emily Harrop
- Helen & Douglas House Hospices, Oxford, UK.,John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Julie Bayliss
- The Louis Dundas Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lynda Brook
- Alder Hey Children's Hospital, Liverpool, UK
| | | | | | - Ian Wong
- UCL School of Pharmacy, London, UK
| | - Christina Liossi
- School of Psychology, University of Southampton, Southampton, UK.,Psychological Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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26
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Guttmann K, Flibotte J, DeMauro SB, Seitz H. A Mixed Methods Analysis of Parental Perspectives on Diagnosis and Prognosis of Neonatal Intensive Care Unit Graduates With Cerebral Palsy. J Child Neurol 2020; 35:336-343. [PMID: 32063083 DOI: 10.1177/0883073820901412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study aimed to evaluate how parents of former neonatal intensive care unit patients with cerebral palsy perceive prognostic discussions following neuroimaging. Parent members of a cerebral palsy support network described memories of prognostic discussions after neuroimaging in the neonatal intensive care unit. We analyzed responses using Linguistic Inquiry and Word Count, manual content analysis, and thematic analysis. In 2015, a total of 463 parents met eligibility criteria and 266 provided free-text responses. Linguistic Inquiry and Word Count analysis showed that responses following neuroimaging contained negative emotion. The most common components identified through the content analysis included outcome, uncertainty, hope/hopelessness, and weakness in communication. Thematic analysis revealed 3 themes: (1) Information, (2) Communication, and (3) Impact. Parents of children with cerebral palsy report weakness in communication relating to prognosis, which persists in parents' memories. Prospective work to develop interventions to improve communication between parents and providers in the neonatal intensive care unit is necessary.
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Affiliation(s)
- Katherine Guttmann
- Division of Newborn Medicine, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, USA
| | - John Flibotte
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, PA, USA
| | - Sara B DeMauro
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, PA, USA
| | - Holli Seitz
- Department of Communication, Mississippi State University, MS, USA
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27
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Lewis-Newby M, Sellers DE, Meyer EC, Solomon MZ, Zurakowski D, Truog RD. Location of Clinician-Family Communication at the End of Life in the Pediatric Intensive Care Unit and Clinician Perception of Communication Quality. J Palliat Med 2020; 23:1052-1059. [PMID: 32182154 DOI: 10.1089/jpm.2019.0511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Communication between clinicians and families of dying children in the pediatric intensive care unit (PICU) is critically important for optimal care of the child and the family. Objective: We examined the current state of clinician perspective on communication with families of dying children in the PICU. Design: Prospective case series over a 15-month study period. Setting/Subjects: We surveyed nurses, psychosocial staff, and physicians who cared for dying children in PICUs at five U.S. academic hospitals. Measurements: Clinicians reported on the location of communication, perceived barriers to end-of-life care, and rated the quality of communication (QOC). Results: We collected 565 surveys from 287 clinicians who cared for 169 dying children. Clinicians reported that the majority of communication occurred at the bedside, and less commonly family conferences and rounds. Ten barriers to care were examined and were reported with frequencies of 2%-32%. QOC was rated higher when the majority of conversations occurred during family conferences (p = 0.01) and lower for patients of non-white race (p = 0.03). QOC decreased when 8 of the 10 barriers to care were reported. Conclusions: When a child is dying, clinicians report that communication with the family occurs most frequently at the child's bedside. This has important implications for future ICU communication research as the majority of previous research and education has focused on family care conferences. In addition, findings that QOC is perceived as lower for non-white patients and when clinicians perceive that barriers hindering care are present can help direct future efforts to improve communication in the PICU.
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Affiliation(s)
- Mithya Lewis-Newby
- Division of Pediatric Critical Care Medicine and Pediatric Bioethics, University of Washington, Seattle, Washington, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Deborah E Sellers
- Bronfenbrenner Center for Translational Research, College of Human Ecology, Cornell University, Ithaca, New York, USA
| | - Elaine C Meyer
- Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mildred Z Solomon
- The Hastings Center, Garrison, New York, USA.,Institute for Professionalism & Ethical Practice, Boston Children's Hospital, Boston, Massachusetts, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert D Truog
- Institute for Professionalism & Ethical Practice, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Medical Ethics and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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28
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Broden EG, Deatrick J, Ulrich C, Curley MAQ. Defining a "Good Death" in the Pediatric Intensive Care Unit. Am J Crit Care 2020; 29:111-121. [PMID: 32114610 PMCID: PMC11288184 DOI: 10.4037/ajcc2020466] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Societal attitudes about end-of-life events are at odds with how, where, and when children die. In addition, parents' ideas about what constitutes a "good death" in a pediatric intensive care unit vary widely. OBJECTIVE To synthesize parents' perspectives on end-of-life care in the pediatric intensive care unit in order to define the characteristics of a good death in this setting from the perspectives of parents. METHODS A concept analysis was conducted of parents' views of a good death in the pediatric intensive care unit. Empirical studies of parents who had experienced their child's death in the inpatient setting were identified through database searches. RESULTS The concept analysis allowed the definition of antecedents, attributes, and consequences of a good death. Empirical referents and exemplar cases of care of a dying child in the pediatric intensive care unit serve to further operationalize the concept. CONCLUSIONS Conceptual knowledge of what constitutes a good death from a parent's perspective may allow pediatric nurses to care for dying children in a way that promotes parents' coping with bereavement and continued bonds and memories of the deceased child. The proposed conceptual model synthesizes characteristics of a good death into actionable attributes to guide bedside nursing care of the dying child.
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Affiliation(s)
- Elizabeth G Broden
- Elizabeth G. Broden is a doctoral student, University of Pennsylvania School of Nursing, and a registered nurse, Pediatric Intensive Care Unit, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Janet Deatrick
- Janet Deatrick is a professor emerita, Department of Family and Community Health, University of Pennsylvania School of Nursing
| | - Connie Ulrich
- Connie Ulrich is a professor, Department of Biobehavioral Health, School of Nursing, and a professor of bioethics, School of Medicine, University of Pennsylvania
| | - Martha A Q Curley
- Martha A.Q. Curley is the Ruth M. Colket Endowed Chair in Pediatric Nursing, Children's Hospital of Philadelphia, and a professor, Department of Family and Community Health, School of Nursing and Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania
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29
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Uveges MK, Milliken A, Alfred A. Role of the Critical Care Nurse in Disclosing Difficult News. AACN Adv Crit Care 2020; 30:287-293. [PMID: 31462527 DOI: 10.4037/aacnacc2019436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Melissa Kurtz Uveges
- Melissa Kurtz Uveges is Postdoctoral Research Fellow, Center for Bioethics at Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 . Aimee Milliken is Wiese Postdoctoral Fellow in Clinical Ethics, Brigham and Women's Hospital, Brighton, Massachusetts. Afi Alfred is Clinical Operations Manager, Bowdoin Street Health Center, Boston, Massachusetts
| | - Aimee Milliken
- Melissa Kurtz Uveges is Postdoctoral Research Fellow, Center for Bioethics at Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 . Aimee Milliken is Wiese Postdoctoral Fellow in Clinical Ethics, Brigham and Women's Hospital, Brighton, Massachusetts. Afi Alfred is Clinical Operations Manager, Bowdoin Street Health Center, Boston, Massachusetts
| | - Afi Alfred
- Melissa Kurtz Uveges is Postdoctoral Research Fellow, Center for Bioethics at Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 . Aimee Milliken is Wiese Postdoctoral Fellow in Clinical Ethics, Brigham and Women's Hospital, Brighton, Massachusetts. Afi Alfred is Clinical Operations Manager, Bowdoin Street Health Center, Boston, Massachusetts
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30
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Weaver MS, Jenkins R, Wichman C, Robinson JE, Potthoff MR, Menicucci T, Vail CA. Sowing Across a State: Development and Delivery of a Grassroots Pediatric Palliative Care Nursing Curriculum. J Palliat Care 2019; 36:22-28. [PMID: 31771423 DOI: 10.1177/0825859719889700] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Rural pediatricians and adult-trained hospice teams report feeling ill-prepared to care for children at end of life, resulting in geographies in which children are not able to access home-based services. OBJECTIVES To develop a pediatric palliative care curriculum for inpatient nurses and adult-trained hospice teams caring for children in a rural region. METHODS Curriculum design and delivery was informed by local culture through an interdisciplinary, iterative development approach with confidence, intention, and support measured pre-, post-, and 4 months after delivery. A needs assessment was completed by pediatric nurses caring for children receiving palliative or end-of-life care to inform curricular content (phase 1). A curriculum was designed by an interdisciplinary pediatric palliative care team and piloted with nursing cohorts annually through educational conferences with monthly discussion series for 3 consecutive years (phase 2). Curricular content was then provided for 31 rural hospice team members (phase 3). RESULTS Self-reported confidence in caring for children increased by 1.1/10 points for adult-trained hospice team members. Mean score for intention to care for children increased by 5.2 points (sustained 5.1 points above baseline at 4 months). Perception of support in caring for children increased by 5 points (mean sustained 5.4 points above baseline at 4 months). Family needs, care goals, and symptom management were prioritized learning topics. Rural hospices previously unwilling to accept children enrolled pediatric patients in the 4 months following the conference. CONCLUSION Grassroots curricular initiatives and ongoing educational mentorship can grow pediatric palliative and hospice services in rural regions.
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Affiliation(s)
- Meaghann S Weaver
- Division of Pediatric Palliative Care, Department of Pediatrics, 20635Children's Hospital and Medical Center, Omaha, NE, USA
| | - Rebecca Jenkins
- Department of Pediatrics, 20635Children's Hospital and Medical Center, Omaha, NE, USA
| | - Christopher Wichman
- Division of Biostatistics, Department of Public Health, 14720University of Nebraska Medical Center, Omaha, NE, USA
| | - Jacob E Robinson
- Division of Pediatric Palliative Care, Department of Pediatrics, 20635Children's Hospital and Medical Center, Omaha, NE, USA
| | | | - Traci Menicucci
- Department of Pediatrics, 20635Children's Hospital and Medical Center, Omaha, NE, USA
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31
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Kolmar A, Hueckel RM, Kamal A, Dickerman M. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Children in Neonatal and Pediatric Intensive Care Units. J Palliat Med 2019; 22:1149-1153. [DOI: 10.1089/jpm.2019.0378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Amanda Kolmar
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
| | - Rémi M. Hueckel
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina
| | - Arif Kamal
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Mindy Dickerman
- Division of Critical Care Medicine, Department of Pediatrics, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware
- Division of Palliative Medicine, Department of Pediatrics, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware
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32
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Uveges MK, Hamilton JB, DePriest K, Boss R, Hinds PS, Nolan MT. The Influence of Parents' Religiosity or Spirituality on Decision Making for Their Critically Ill Child: An Integrative Review. J Palliat Med 2019; 22:1455-1467. [PMID: 31369318 DOI: 10.1089/jpm.2019.0154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Religion and/or spirituality are important values for many parents of critically ill children; however, how religion and/or spirituality may influence which treatments parents accept or decline for their child, or how they respond to significant events during their child's illness treatment, remains unclear. Objective: To summarize the literature related to the influence of parents' religiosity or spirituality on decision making for their critically ill child. Design: Integrative review, using the Whittemore and Knafl approach. Setting/Subjects: Data were collected from studies identified through PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL plus), Embase, Scopus, and PsychInfo. Databases were searched to identify literature published between 1996 and 2016. Results: Twenty-four articles of variable methodological quality met inclusion criteria. Analysis generated three themes: parents' religiosity or spirituality as (1) guidance during decision making, (2) comfort and support during the decision-making process, and (3) a source of meaning, purpose, and connectedness in the experience of decision making. Conclusion: This review suggests that parents' religiosity and/or spirituality is an important and primarily positive influence on their decision making for a critically ill child.
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Affiliation(s)
- Melissa Kurtz Uveges
- Department of Global Health and Social Medicine, Center for Bioethics, Harvard Medical School, Boston, Massachusetts
| | - Jill B Hamilton
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Kelli DePriest
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Renee Boss
- Division of Neonatal-Perinatal Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Pamela S Hinds
- Department of Nursing Research and Quality Outcomes, Children's National Health System, Washington, DC
| | - Marie T Nolan
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
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Gómez-Zúñiga B, Pulido Moyano R, Pousada Fernández M, García Oliva A, Armayones Ruiz M. The experience of parents of children with rare diseases when communicating with healthcare professionals: towards an integrative theory of trust. Orphanet J Rare Dis 2019; 14:159. [PMID: 31253163 PMCID: PMC6599337 DOI: 10.1186/s13023-019-1134-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/12/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Given the inherent complexity of rare paediatric diseases and the sensitive emotional context of the situations they create (due to the patients' age and the tense uncertainty surrounding the progression of the disease), communication between the adults involved is a key tool in the efforts to provide these children and youths a better quality of life. We conducted ten interviews with families of children with rare diseases, in the aim of exploring how communication between doctors and patients affect their daily lives. All participants, members of FEDER (a Spanish federation of associations of patients with rare diseases) were invited by phone or email to participate in a semi-structured interview including questions on clinical information, communication experiences with healthcare professionals, and the impact these had on the interviewees' relationships with them. To analyse these interviews, we used the 'grounded theory' methodology and open and axial text coding techniques, in addition to those identifying the properties and dimensions of the categories formulated. RESULTS The core category we have proposed is 'adjustment of mutual trust', with said category describing the attitude and behaviour of doctors who inspire trust in the parents of paediatric patients diagnosed with a rare disease. More specifically, said behaviours or sources of trust are: appearing human, sensitive and empathetic; showing transparency and communicative openness; being supportive of parental proactivity; and being available to families at all times. CONCLUSIONS Trust is the cornerstone of parent-doctor communication in the field of children with rare diseases. If the sources of trust are present, they create a degree of trust that bolsters both parties in the search for a common goal: providing the child with the best possible care.
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Affiliation(s)
- Beni Gómez-Zúñiga
- Estudis de Psicologia i Ciències de l'Educació, Universitat Oberta de Catalunya, Rambla Poblenou, 156 08018, Barcelona, Spain.
| | - Rafael Pulido Moyano
- Edificio Departamental de Humanidades y Ciencias de la Educación I (Edif. A). Planta 2, despacho 14, Universidad de Almería, Ctra. Sacramento s/n, La Cañada de San Urbano, 04120, Almería, Spain
| | - Modesta Pousada Fernández
- Estudis de Psicologia i Ciències de l'Educació, Universitat Oberta de Catalunya, Rambla Poblenou, 156 08018, Barcelona, Spain
| | | | - Manuel Armayones Ruiz
- eHealth Center, Estudis de Psicologia i Ciències de l'Educació, Universitat Oberta de Catalunya, Ctra. Sacramento s/n, La Cañada de San Urbano, 04120, Barcelona, Spain
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Mitchell S, Spry JL, Hill E, Coad J, Dale J, Plunkett A. Parental experiences of end of life care decision-making for children with life-limiting conditions in the paediatric intensive care unit: a qualitative interview study. BMJ Open 2019; 9:e028548. [PMID: 31072863 PMCID: PMC6528052 DOI: 10.1136/bmjopen-2018-028548] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To provide an in-depth insight into the experience and perceptions of bereaved parents who have experienced end of life care decision-making for children with life-limiting or life-threatening conditions in the paediatric intensive care unit (PICU). DESIGN An in-depth qualitative interview study with a sample of parents of children with life-limiting or life-threatening conditions who had died in PICU within the previous 12 months. A thematic analysis was conducted on the interview transcripts. SETTING A PICU in a large National Health Service (NHS) tertiary children's hospital in the West Midlands, UK. PARTICIPANTS 17 parents of 11 children who had died in the PICU. RESULTS Five interconnected themes were identified related to end of life care decision-making:(1) parents have significant knowledge and experiences that influence the decision-making process.(2) Trusted relationships with healthcare professionals are key to supporting parents making end of life decisions.(3) Verbal and non-verbal communication with healthcare professionals impacts on the family experience.(4) Engaging with end of life care decision-making can be emotionally overwhelming, but becomes possible if parents reach a 'place of acceptance'.(5) Families perceive benefits to receiving end of life care for their child in a PICU. CONCLUSIONS AND IMPLICATIONS The death of a child is an intensely emotional experience for all involved. This study adds to the limited evidence base related to parental experiences of end of life care decision-making and provides findings that have international relevance, particularly related to place of care and introduction of end of life care discussions. The expertise and previous experience of parents is highly relevant and should be acknowledged. End of life care decision-making is a complex and nuanced process; the information needs and preferences of each family are individual and need to be understood by the professionals involved in their care.
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Affiliation(s)
- Sarah Mitchell
- Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Jenna L Spry
- Paediatric Intensive Care Unit, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Emma Hill
- Paediatric Intensive Care Unit, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Jane Coad
- School of Health Sciences, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Adrian Plunkett
- Paediatric Intensive Care Unit, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, Birmingham, UK
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Brock KE, Tracewski M, Allen KE, Klick J, Petrillo T, Hebbar KB. Simulation-Based Palliative Care Communication for Pediatric Critical Care Fellows. Am J Hosp Palliat Care 2019; 36:820-830. [PMID: 30974949 DOI: 10.1177/1049909119839983] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pediatric palliative care (PPC) education is lacking in pediatric critical care medicine (PCCM) fellowships, despite the desire of many program directors and fellows to expand difficult conversation training. Simulation-based training is an experiential method for practicing challenging communication skills such as breaking bad news, disclosing medical errors, navigating goals of care, and supporting medical decision-making. METHODS We describe a simulation-based PPC communication series for PCCM fellows, including presimulation session, simulation session, debriefing, and evaluation methods. From 2011 to 2017, 28 PCCM fellows participated in a biannual half-day simulation session. Each session included 3 scenarios (allowing for participation in up to 18 scenarios over 3 years). Standardized patients portrayed the child's mother. PCCM and interprofessional PPC faculty cofacilitated, evaluated, and debriefed the fellows after each scenario. Fellows were evaluated in 4 communication categories (general skills, breaking bad news, goals of care, and resuscitation) using a 3-point scale. A retrospective descriptive analysis was conducted. RESULTS One hundred sixteen evaluations were completed for 18 PCCM fellows. Median scores for general communication items, breaking bad news, and goals of care ranged from 2.0 to 3.0 (interquartile range [IQR]: 0-1) with scores for resuscitation lower at 1.0 (IQR: 1.5-2). DISCUSSION This experiential simulation-based PPC communication curriculum taught PCCM fellows valuable palliative communication techniques although revealed growth opportunities within more complex communication tasks. The preparation, methods, and lessons learned for an effective palliative simulation curriculum can be expanded upon by other pediatric training programs, and a more rigorous research program should be added to educational series.
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Affiliation(s)
- Katharine E Brock
- 1 Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, GA, USA.,2 Division of Pediatric Hematology/Oncology, Department of Pediatrics, Emory University, Atlanta, GA, USA.,3 Pediatric Palliative Care, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Meghan Tracewski
- 3 Pediatric Palliative Care, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kristen E Allen
- 1 Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jeffrey Klick
- 3 Pediatric Palliative Care, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Toni Petrillo
- 4 Division of Critical Care Medicine, Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Kiran B Hebbar
- 4 Division of Critical Care Medicine, Department of Pediatrics, Emory University, Atlanta, GA, USA
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Steele R, Bosma H, Johnston MF, Cadell S, Davies B, Siden H, Straatman L. Research Priorities in Pediatric Palliative Care: A Delphi Study. J Palliat Care 2019. [DOI: 10.1177/082585970802400402] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rose Steele
- School of Nursing, Faculty of Health, York University, Toronto, Ontario
| | - Harvey Bosma
- School of Social Work, University of British Columbia, Vancouver, British Columbia
| | | | - Susan Cadell
- Faculty of Social Work, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Betty Davies
- Department of Family Health Care Nursing, University of California, San Francisco, California, USA
| | - Hal Siden
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Lynn Straatman
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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37
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Edwards JD, Kun SS, Graham RJ, Keens TG. End-Of-Life Discussions and Advance Care Planning for Children on Long-Term Assisted Ventilation with Life-Limiting Conditions. J Palliat Care 2018. [DOI: 10.1177/082585971202800104] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Families of children with life-limiting conditions who are on long-term assisted ventilation need to undertake end-of-life advance care planning (ACP) in order to align their goals and values with the inevitability of their child's condition and the risks it entails. To discuss how best to conduct ACP in this population, we performed a retrospective analysis of end-of-life discussions involving our deceased ventilator-assisted patients between 1987 and 2009. A total of 34 (72 percent) of 47 study patients were the subject of these discussions; many discussions occurred after acute deterioration. They resulted in directives to forgo or limit interventions for 21 children (45 percent). We surmise that many families were hesitant to discuss end-of-life issues during periods of relative stability. By offering anticipatory guidance and encouraging contemplation of patients’ goals both in times of stability and during worsening illness, health care providers can better engage patients’ families in ACP. As the child's condition progresses, the emphasis can be recalibrated. How families respond to such encouragement can also serve as a gauge of their willingness to pursue ACP.
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Affiliation(s)
- Jeffrey D. Edwards
- JD Edwards (corresponding author): Division of Pediatric Critical Care, University of California, San Francisco, and Moffitt Hospital, Box 0106, 505 Parnassus Avenue, San Francisco, California, USA 94143–0106
| | - Sheila S. Kun
- SS Kun: Division of Pediatric Pulmonology, Children's Hospital Los Angeles, and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert J. Graham
- RJ Graham: Critical Care, Anesthesia, Perioperative Extension (CAPE) and Home Ventilation Program, and Division of Critical Care Medicine, Children's Hospital Boston, and Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas G. Keens
- TG Keens: Division of Pediatric Pulmonology, Children's Hospital Los Angeles, and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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38
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von Lützau P, Otto M, Hechler T, Metzing S, Wolfe J, Zernikow B. Children Dying from Cancer: Parents’ Perspectives on Symptoms, Quality of Life, Characteristics of Death, and End-of-Life Decisions. J Palliat Care 2018. [DOI: 10.1177/082585971202800406] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this study, we investigated the experience of children who died of cancer, as perceived by their parents. All the pediatric oncology departments in one German federal state were contacted and asked to invite parents who had lost a child to cancer in the period 2005–2006 to participate. Those parents who accepted were interviewed by means of a semi-structured questionnaire. In the participating 16 departments, 158 children died in 2005–2006. Parents of 48 children (38.3 percent) agreed to participate and were interviewed. Nearly all of the children had suffered from at least one distressing symptom. Pain and fatigue occurred most frequently. Symptoms were successfully treated over 65 percent of the time. In all, 64 percent of the children received home care services; 50 percent died at home, and only 10 percent in the ICU. Results suggest that some progress has been made in pediatric palliative care. To further improve end-of-life care for children with cancer, it is also necessary to evaluate parents’ perspectives on structures for pediatric palliative care delivery.
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Affiliation(s)
- Pia von Lützau
- P von Lützau (corresponding author): Pediatric Palliative Care Centre and German Pediatric Pain Centre, Children's and Adolescents’ Hospital, Datteln and Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health — School of Medicine, Dr. Friedrich Steiner Strasse 5, 45711 Datteln, Germany
| | - Michael Otto
- M Otto, T Hechler, B Zernikow: Pediatric Palliative Care Centre and German Pediatric Pain Centre, Children's and Adolescents’ Hospital, Datteln and Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health — School of Medicine, Datteln, Germany
| | - Tanja Hechler
- M Otto, T Hechler, B Zernikow: Pediatric Palliative Care Centre and German Pediatric Pain Centre, Children's and Adolescents’ Hospital, Datteln and Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health — School of Medicine, Datteln, Germany
| | - Sabine Metzing
- M Otto, T Hechler, B Zernikow: Pediatric Palliative Care Centre and German Pediatric Pain Centre, Children's and Adolescents’ Hospital, Datteln and Department of Children's Pain Therapy and Paediatric Palliative Care, Witten/Herdecke University, Faculty of Health — School of Medicine, Datteln, Germany
| | - Joanne Wolfe
- S Metzing: Witten/Herdecke University, Faculty of Health — School of Nursing Science, Witten, Germany
| | - Boris Zernikow
- J Wolfe: Harvard Medical School, and Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts, USA
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Butler AE, Hall H, Copnell B. Bereaved parents' experiences of research participation. BMC Palliat Care 2018; 17:122. [PMID: 30404631 PMCID: PMC6223065 DOI: 10.1186/s12904-018-0375-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background As understandings of the impacts of end-of-life experiences on parents’ grief and bereavement increase, so too does the inclusion of bereaved parents into research studies exploring these experiences. However, designing and obtaining approval for these studies can be difficult, as guidance derived from bereaved parents’ experiences of the research process are limited within the current literature. Methods We aimed to explore bereaved parents’ experiences of research participation in a larger grounded theory study exploring experiences of the death of a child in the paediatric intensive care unit. Data were obtained during follow-up phone calls made to 19 bereaved parents, five of whom provided data from their spouse, 1 week after their participation in the study. Participants were asked to reflect on their experiences of research participation, with a focus on recruitment methods, timing of research contact, and the location of their interview. Parents’ responses were analysed using descriptive content analysis. Results Our findings demonstrate that despite being emotionally difficult, parents’ overall experiences of research participation were positive. Parents preferred to be contacted initially via a letter, with an opt in approach viewed most favourably. Most commonly, participants preferred that research contact occurred within 12–24 months after their child’s death, with some suggesting contact after 6 months was also appropriate. Parents also preferred research interviews conducted in their own homes, though flexibility and parental choice was crucial. Conclusions Findings from this study offer further insight to researchers and research review committees, to help ensure that future studies are conducted in a way that best meets the unique needs of bereaved parents participating in research.
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Affiliation(s)
- Ashleigh E Butler
- The Louis Dundas Centre for Children's Palliative Care, University College London Great Ormond Street Institute of Child Health, London, UK. .,School of Nursing and Midwifery, Monash University, Melbourne, Australia.
| | - Helen Hall
- School of Nursing and Midwifery, Monash University, Melbourne, Australia
| | - Beverley Copnell
- School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
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de Saint Blanquat L, Viallard ML. Réflexions éthiques et démarche palliative intégrée dans les réanimations pédiatriques françaises en 2017. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
En réanimation pédiatrique, 40 % des décès surviennent à la suite d’une décision de limitation ou d’arrêt de traitement (LAT). Ces situations sont sources de questionnements éthiques complexes au sein de l’équipe soignante. La législation française et les recommandations des sociétés savantes donnent un cadre aux réanimateurs pédiatres pour les prises de décisions de LAT. Les enquêtes de pratiques nous montrent qu’ils se sont approprié certains éléments de la procédure collégiale comme la nécessité de la concertation pluriprofessionnelle, l’information et la communication avec les parents. Néanmoins, certains points tels que la présence du consultant, la réalité de la collégialité avec l’expression de toutes les personnes soignantes présentes sont encore insuffisamment appliqués. La place des parents dans les décisions doit être également réfléchie. La collaboration entre les équipes de réanimation pédiatrique et de médecine palliative est une possibilité pour améliorer sensiblement la qualité des soins et de l’accompagnement proposés. Cette collaboration élargit également les possibilités de la réflexion éthique nécessaire dans les situations de fin de vie complexes. L’intégration dans l’enseignement de la réanimation des principes de la médecine palliative est en cours de réflexion.
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Superdock AK, Barfield RC, Brandon DH, Docherty SL. Exploring the vagueness of Religion & Spirituality in complex pediatric decision-making: a qualitative study. BMC Palliat Care 2018; 17:107. [PMID: 30208902 PMCID: PMC6134505 DOI: 10.1186/s12904-018-0360-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 08/31/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Medical advances have led to new challenges in decision-making for parents of seriously ill children. Many parents say religion and spirituality (R&S) influence their decisions, but the mechanism and outcomes of this influence are unknown. Health care providers (HCPs) often feel unprepared to discuss R&S with parents or address conflicts between R&S beliefs and clinical recommendations. Our study sought to illuminate the influence of R&S on parental decision-making and explore how HCPs interact with parents for whom R&S are important. METHODS A longitudinal, qualitative, descriptive design was used to (1) identify R&S factors affecting parental decision-making, (2) observe changes in R&S themes over time, and (3) learn about HCP perspectives on parental R&S. The study sample included 16 cases featuring children with complex life-threatening conditions. The length of study for each case varied, ranging in duration from 8 to 531 days (median = 380, mean = 324, SD = 174). Data from each case included medical records and sets of interviews conducted at least monthly with mothers (n = 16), fathers (n = 12), and HCPs (n = 108). Thematic analysis was performed on 363 narrative interviews to identify R&S themes and content related to decision-making. RESULTS Parents from 13 cases reported R&S directly influenced decision-making. Most HCPs were unaware of this influence. Fifteen R&S themes appeared in parent and HCP transcripts. Themes most often associated with decision-making were Hope & Faith, God is in Control, Miracles, and Prayer. Despite instability in the child's condition, these themes remained consistently relevant across the trajectory of illness. R&S influenced decisions about treatment initiation, procedures, and life-sustaining therapy, but the variance in effect of R&S on parents' choices ultimately depended upon other medical & non-medical factors. CONCLUSIONS Parents consider R&S fundamental to decision-making, but apply R&S concepts in vague ways, suggesting R&S impact how decisions are made more than what decisions are made. Lack of clarity in parental expressions of R&S does not necessarily indicate insincerity or underestimation of the seriousness of the child's prognosis; R&S can be applied to decision-making in both functional and dysfunctional ways. We present three models of how religious and spiritual vagueness functions in parental decision-making and suggest clinical applications.
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Affiliation(s)
- Alexandra K. Superdock
- School of Medicine, Duke University, Durham, NC USA
- Pediatrics Residency Program, University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, 15224 PA USA
| | - Raymond C. Barfield
- Division of Pediatric Hematology and Oncology, Duke University School of Medicine, 2 Chapel Drive, 0034 Westbrook, Durham, NC 27708 USA
| | - Debra H. Brandon
- Department of Pediatrics, Duke University School of Nursing, 307 Trent Drive, Durham, NC 27710 USA
- School of Nursing, Duke University, 307 Trent Drive, Durham, NC 27710 USA
| | - Sharron L. Docherty
- Department of Pediatrics, Duke University School of Nursing, 307 Trent Drive, Durham, NC 27710 USA
- School of Nursing, Duke University, 307 Trent Drive, Durham, NC 27710 USA
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Goymour KL, Heaton M, Coombs S, Kelk N, Estreich K, Sarraf S, Trethewie S, Jaaniste T. Developing the Comfort Care Case: An End-of-Life Resource for Pediatric Patients, Their Families, and Health Professionals. J Palliat Care 2018; 34:197-204. [PMID: 30168359 DOI: 10.1177/0825859718796791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Caring for a child in hospital who is approaching death, in the terminal phase, requires a focus on caring for the physical, emotional, and spiritual needs of the child and family. Health professionals caring for these children and families may need to shift their focus from a treatment-focused approach aimed at cure or maintaining life to a comfort-focused approach. The Comfort Care Case (CCC) is a collection of resources designed for use in hospital to ease suffering and facilitate comfort within a pediatric end-of-life (EOL) context. The resources are intended to support the child, the family, and the health professionals involved in EOL care. This article describes the development, implementation, and education associated with the CCC in a tertiary pediatric hospital.
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Affiliation(s)
- Kirsty-Leah Goymour
- 1 Department of Palliative Care, Sydney Children's Hospital, Randwick, New South Wales, Australia.,2 Child Life and Music Therapy Department, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Maria Heaton
- 1 Department of Palliative Care, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Sandra Coombs
- 1 Department of Palliative Care, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Norm Kelk
- 1 Department of Palliative Care, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Kylie Estreich
- 2 Child Life and Music Therapy Department, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Sara Sarraf
- 1 Department of Palliative Care, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Susan Trethewie
- 1 Department of Palliative Care, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Tiina Jaaniste
- 1 Department of Palliative Care, Sydney Children's Hospital, Randwick, New South Wales, Australia.,3 School of Women's and Children's Health, University of New South Wales, Kensington, New South Wales, Australia
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Foe G, Hellmann J, Greenberg RA. Parental Moral Distress and Moral Schism in the Neonatal ICU. JOURNAL OF BIOETHICAL INQUIRY 2018; 15:319-325. [PMID: 29802588 DOI: 10.1007/s11673-018-9858-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/28/2018] [Indexed: 05/22/2023]
Abstract
Ethical dilemmas in critical care may cause healthcare practitioners to experience moral distress: incoherence between what one believes to be best and what occurs. Given that paediatric decision-making typically involves parents, we propose that parents can also experience moral distress when faced with making value-laden decisions in the neonatal intensive care unit. We propose a new concept-that parents may experience "moral schism"-a genuine uncertainty regarding a value-based decision that is accompanied by emotional distress. Schism, unlike moral distress, is not caused by barriers to making and executing a decision that is deemed to be best by the decision-makers but rather an encounter of significant internal struggle. We explore factors that appear to contribute to both moral distress and "moral schism" for parents: the degree of available support, a sense of coherence of the situation, and a sense of responsibility. We propose that moral schism is an underappreciated concept that needs to be explicated and may be more prevalent than moral distress when exploring decision-making experiences for parents. We also suggest actions of healthcare providers that may help minimize parental "moral schism" and moral distress.
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Affiliation(s)
- Gabriella Foe
- Bioethics Department, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jonathan Hellmann
- Bioethics Department, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Rebecca A Greenberg
- Bioethics Department, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Department of Paediatrics, University of Toronto, Toronto, Canada.
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44
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Youngblut JM, Brooten D. Comparison of mothers and grandmothers physical and mental health and functioning within 6 months after child NICU/PICU death. Ital J Pediatr 2018; 44:89. [PMID: 30097046 PMCID: PMC6086060 DOI: 10.1186/s13052-018-0531-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 08/06/2018] [Indexed: 11/12/2022] Open
Abstract
Background Losing a child is devastating for parents and grandparents. Family and friends generally focus on comforting and supporting the bereaved parents, unintentionally ignoring the bereaved grandparents. Grandmothers and grandfathers often struggle with wanting to help their adult children (deceased child’s parents) without usurping the parents’ responsibilities and decisions regarding the deceased child. Research on mothers’ and grandmothers’ health at about the same time after the same child’s death in the neonatal or pediatric intensive care unit is lacking. The aim of this study was to compare mothers and grandmothers on physical health, mental health, and functioning in the first 1–6 months after the same child’s death in a neonatal or pediatric intensive care unit. Methods This cross-sectional secondary analysis compared 32 mothers with 32 grandmothers of the same 32 deceased children (newborn-6 years). Grandmothers were recruited through these 32 mothers. Most grandmothers and mothers were Hispanic (25%, 34%) or Black (44%, 41%), respectively. Mothers and grandmothers separately completed questions about their Physical Health, Mental Health [depression (Beck Depression Inventory), Post-Traumatic Stress Disorder (PTSD, Impact of Events-R), grief (Hogan Grief Reaction Checklist)], and Functioning (social support [MSPSS] and Employment) since the child’s/grandchild’s death. Paired t-tests and Chi Square tests were used to compare grandmothers with mothers of the same deceased infant/child on their private and separate responses to study measures. Results Mothers had significantly more acute illnesses than grandmothers. More mothers (63%) than grandmothers (37%) were categorized as clinically depressed. More mothers (69%) than grandmothers (44%) had clinical PTSD. Mothers reported significantly higher levels of despair and detachment than grandmothers. Only 4 mothers and 2 grandmothers were in therapy at the time of interview. Grandmothers and mothers rated their ability to concentrate on their work and their level of social support similarly. Conclusions Mothers had more acute illnesses, more severe depression, and a higher level of grief than grandmothers. However, few received therapy despite their high levels of depressive and PTSD symptoms.
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Affiliation(s)
- JoAnne M Youngblut
- Nicole Wertheim College of Nursing & Health Sciences, Florida International University, AHC 3, Rm 241, 11200 SW 8th St., Miami, FL, 33199, USA.
| | - Dorothy Brooten
- Nicole Wertheim College of Nursing & Health Sciences, Florida International University, AHC 3, Rm 241, 11200 SW 8th St., Miami, FL, 33199, USA
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Butler AE, Hall H, Copnell B. Gradually Disengaging: Parent-Health care Provider Relationships After a Child's Death in the Pediatric Intensive Care Unit. JOURNAL OF FAMILY NURSING 2018; 24:470-492. [PMID: 29938568 DOI: 10.1177/1074840718783470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
When a child dies in the intensive care unit, many bereaved parents want relationships with their child's health care staff to continue in the form of follow-up care. However, the nature of these relationships and how they change across the parents' bereavement journey is currently unknown. This article explores early and ongoing relationships between parents and health care staff when a child dies in intensive care. Constructivist grounded theory methods were used to recruit 26 bereaved parents from four Australian pediatric intensive care units into the study. Data were collected via audio-recorded, semistructured interviews and analyzed using the constant comparative methods and theoretical memoing. Findings show that these relationships focus on Gradually disengaging, commonly moving through three phases after the child dies: Saying goodbye, Going home, and Seeking supports. These findings provide guidance to health care staff on what families need as they leave the intensive care unit and move through bereavement.
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Affiliation(s)
- Ashleigh E Butler
- 1 Louis Dundas Centre for Children's Palliative Care, University College London Institute for Child Health, UK
| | - Helen Hall
- 2 Monash University, Frankston, Victoria, Australia
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Wilson PM, Herbst LA, Gonzalez-del-Rey J. Development and Implementation of an End-of-Life Curriculum for Pediatric Residents. Am J Hosp Palliat Care 2018; 35:1439-1445. [DOI: 10.1177/1049909118786870] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Caring for a child near the end of life (EOL) can be a stressful experience. Resident physicians are often the frontline providers responsible for managing symptoms, communicating difficult information, and pronouncing death, yet they often receive minimal education on EOL care. Objective: To develop and implement an EOL curriculum and to study its impact on resident comfort and attitudes surrounding EOL care. Design: Kern’s 6-step approach to curriculum development was used as a framework for curriculum design and implementation. Setting/Participants: Categorical and combined pediatric residents at a large quaternary care children’s hospital were exposed to the curriculum. Measurements: A cross-sectional survey was distributed pre- and postimplementation of the curriculum to evaluate its impact on resident comfort and attitudes surrounding EOL care. Results: One-hundred twenty-six (49%) of 258 residents completed the preimplementation survey, and 65 (32%) of 201 residents completed the postimplementation survey. Over 80% of residents reported caring for a dying patient, yet less than half the residents reported receiving prior education on EOL care. Following curriculum implementation, the percentage of residents dissatisfied with their EOL education fell from 36% to 14%, while the percentage of residents satisfied with their education increased from 14% to 29%. The postimplementation survey identified that resident comfort with communication-based topics improved, and they sought additional training in symptom management. Conclusions: The implementation of a longitudinal targeted multimodal EOL curriculum improved resident satisfaction with EOL education and highlighted the need for additional EOL education.
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Affiliation(s)
- Paria M. Wilson
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lori A. Herbst
- Division of Hospital Medicine, Department of Pediatrics and General Internal Medicine, Cincinnati Children’s Hospital Medical Center, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Javier Gonzalez-del-Rey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Donohue PK, Williams EP, Wright-Sexton L, Boss RD. “It's Relentless”: Providers' Experience of Pediatric Chronic Critical Illness. J Palliat Med 2018; 21:940-946. [DOI: 10.1089/jpm.2017.0397] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Pamela K. Donohue
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Population, Family, and Reproductive Health, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Erin P. Williams
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland
| | - Laura Wright-Sexton
- Division of Critical Care Medicine, Department of Pediatrics, University of Mississippi, Mississippi, Missouri
| | - Renee D. Boss
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland
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Lamiani G, Ciconali M, Argentero P, Vegni E. Clinicians’ moral distress and family satisfaction in the intensive care unit. J Health Psychol 2018; 25:1894-1904. [DOI: 10.1177/1359105318781935] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study explored the relationship between clinicians’ moral distress and family satisfaction with care in five intensive care units in Italy. A total of 122 clinicians (45 physicians and 77 nurses) and 59 family members completed the Italian Moral Distress Scale-Revised and the Family Satisfaction in the ICU questionnaire, respectively. Clinicians’ moral distress inversely correlated with family satisfaction related to the inclusion in the decision-making process. Specifically, physicians’ moral distress inversely correlated with satisfaction regarding the respect shown toward the patient. Nurses’ moral distress inversely correlated with satisfaction regarding breathlessness and agitation management, provision of emotional support, understanding of information, and inclusion in the decision-making process.
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Affiliation(s)
- Giulia Lamiani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Matteo Ciconali
- Department of Health Sciences, University of Milan, Milan, Italy
| | | | - Elena Vegni
- Department of Health Sciences, University of Milan, Milan, Italy
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Zaal-Schuller IH, Willems DI, Ewals F, van Goudoever JB, de Vos MA. Involvement of nurses in end-of-life discussions for severely disabled children. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2018; 62:330-338. [PMID: 29388276 DOI: 10.1111/jir.12473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/08/2017] [Accepted: 12/21/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND In children with profound intellectual and multiple disabilities (PIMD), discussions about end-of-life decisions (EoLDs) are comparatively common. Nurses play a crucial role in the care for these children, yet their involvement in EoLD discussions is largely unknown. The objective of this research was to investigate the involvement in the hospital of nurses in discussions with parents and physicians about EoLDs for children with PIMD. METHOD In a retrospective, qualitative study, we conducted semi-structured interviews with the nurses of 12 children with PIMD for whom an EoLD was made within the past 2 years. RESULTS Parents primarily discuss EoLDs with nurses before and after the meeting with the physician. Nurses who were involved in EoL discussions with parents and physicians assisted them by giving factual information about the child and by providing emotional support. Some nurses, especially nurses from ID-care services, were not involved in EoL discussions, even if they had cared for the child for a long period of time. Some of the nurses had moral or religious objections to carrying out the decisions. CONCLUSION Most nurses were not involved in EoL discussions with parents and physicians in the hospital. Excluding nurses from EoL discussions can cause them moral distress. The involvement of nurses in EoL discussions for children with PIMD should be improved, especially by involving nurses from ID-care services. Because these nurses are usually familiar with the child, they can be valuable sources of information about the child's quality of life.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medial Ethics, Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
| | - D I Willems
- Section of Medial Ethics, Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
| | - F Ewals
- Intellectual Disability Medicine, Department of Medical Practice, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - J B van Goudoever
- Department of Pediatrics, VU Medisch Centrum, Amsterdam, the Netherlands
- Academic Medical Centre, Emma's Children's Hospital, Department of Paediatrics, Amsterdam, The Netherlands
| | - M A de Vos
- Section of Medial Ethics, Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
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