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Tadros HJ, Saidi A, Rawlinson AR, Cattier C, Black EW, Rackley J, Breault L, Pietra BA, Fricker FJ, Gupta D. Assessment of parental decision making in congenital heart disease, cardiomyopathy and heart transplantation: an observational study analysing decisional characteristics and preferences. Arch Dis Child 2023:archdischild-2022-324373. [PMID: 36732035 DOI: 10.1136/archdischild-2022-324373] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE We explore shared decision making (DM) in guardians of children with heart disease by assessing the desired weight of influence on DM and factors that may alter the relative weight of parent or medical team influence. METHODS Guardians of patients <21 years and admitted >1 week in the paediatric cardiac intensive care unit (PCICU) were recruited. Twelve vignettes were designed including technical (antibiotic selection, intubation, peripherally inserted central catheter placement, ventricular assist device placement, heart transplant, organ rejection, heart rhythm abnormalities and resuscitation effort) and non-technical vignettes (cessation of life-sustaining therapies, depression treatment, obesity and palliative care referral). Participants responded to questions on DM characteristics and one question querying preference for relative weight of parent or medical team influence on DM. RESULTS Of 209 participants approached, 183 were included. Most responded with equal desire of medical team and parental influence on DM in all vignettes (range 41.0%-66.7%). Technical scenarios formed one cluster based on DM characteristics, compared with non-technical scenarios. Factors that increase the relative weight of parental influence on DM include desired input and involvement in big-picture goals (OR 0.274, CI [0.217 to 0.346]; OR 0.794, CI [0.640 to 0.986]). Factors that increase the relative weight of medical team influence on DM include perception of medical expertise needed (OR 1.949 [1.630 to 2.330]), urgency (OR 1.373 [1.138 to 1.658]), benefit (OR 1.415 [1.172 to 1.710]), number of PCICU admissions (OR 1.134 [1.024 to 1.256]) and private insurance (OR 1.921 [1.144 to 3.226]). CONCLUSION Although factors may alter the weight of influence on DM, most parents desire equal parental and medical team influence on DM.
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Affiliation(s)
- Hanna J Tadros
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Arwa Saidi
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Alana R Rawlinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Celine Cattier
- Department of Palliative Care, University of Florida, Gainesville, Florida, USA
| | - Erik W Black
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Jennifer Rackley
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Leah Breault
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Biagio A Pietra
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Fredrick J Fricker
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Dipankar Gupta
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA .,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
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2
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Stewart S, Briggs KB, Fraser JA, Svetanoff WJ, Waddell V, Oyetunji TA. Pre-hospital CPR after traumatic arrest: Outcomes at a level 1 pediatric trauma center. Injury 2023; 54:15-18. [PMID: 36229246 DOI: 10.1016/j.injury.2022.09.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 09/21/2022] [Accepted: 09/28/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The survival of traumatic cardiopulmonary arrest (TCA) requiring pre-hospital cardiopulmonary resuscitation (P-CPR) is abysmal across age groups. We aim to describe the mechanisms of injury and outcomes of children suffering from TCA leading to P-CPR at our institution. METHODS A retrospective review was conducted to identify children ages 0-17 years who suffered TCA leading to P-CPR at our institution between 5/2009 and 3/2020. For analysis, patients were stratified into those still undergoing CPR at arrival and those who attained pre-hospital return of spontaneous circulation (ROSC). Primary outcome was discharge alive from the hospital. RESULTS P-CPR was initiated for 48 patients who had TCA; 23 had pre-hospital ROSC. Of the 25 children undergoing CPR at presentation, none survived to discharge. The median duration of CPR, from initiation to time of death declaration was 34 min [29,50]. Seventeen patients died after resuscitation attempts in the ED, while 8 died after admission to the PICU. Of the 23 patients who attained pre-hospital ROSC, 6 survived to discharge. All survivors required intensive rehabilitation services at discharge and at most recent follow-up, 5 had residual deficits requiring medical attention. CONCLUSION There are poor outcomes in children with pre-hospital traumatic cardiopulmonary arrest, particularly in those without pre-hospital ROSC. These data further support the need for standardized guidelines for resuscitation in children with traumatic cardiopulmonary arrest.
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Affiliation(s)
- Shai Stewart
- Department of Surgery, Children's Mercy Hospital, United States; School of Medicine, Kansas City University, United States.
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy Hospital, United States; School of Medicine, Kansas City University, United States
| | - James A Fraser
- Department of Surgery, Children's Mercy Hospital, United States; School of Medicine, Kansas City University, United States
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Hospital, United States; School of Medicine, Kansas City University, United States
| | - Valerie Waddell
- Department of Surgery, Children's Mercy Hospital, United States; School of Medicine, Kansas City University, United States
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Hospital, United States; Quality Improvement and Surgical Equity Research (QISER) Center, United States; School of Medicine, Kansas City University, United States
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3
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Choi J, Choi AY, Park E, Son MH, Cho J. Effect of life-sustaining treatment decision law on pediatric in-hospital cardiopulmonary resuscitation rate: A Korean population-based study. Resuscitation 2022; 180:38-44. [PMID: 36176228 DOI: 10.1016/j.resuscitation.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 11/19/2022]
Abstract
AIM The 2018 life-sustaining treatment (LST) decision law is expected to improve end-of-life quality in Korea. This study evaluated the national effect of the LST decision law on the cardiopulmonary resuscitation (CPR) rate among pediatric patients who died during hospital admission. METHODS This retrospective cohort study was based on the Korean National Health Insurance database. Pediatric admissions within 12 months before or after implementation of the LST decision law were compared, allowing a 1-month transition period (February 2018). The changes in mortality, CPR, and documentation of LST decision were evaluated. RESULTS The CPR rate of patients who died in hospital decreased after establishment of the LST decision law (49.6 vs 43.4 %, P = 0.04), without change of in-hospital mortality between pre/post-LST decision law activation (0.83 vs 0.81 per 1000 admissions, P = 0.67). In addition, in-hospital CPR (0.73 vs 0.67 per 1000 admissions, P = 0.15) and survival to discharge after in-hospital CPR (43.6 vs 47.2 %, P = 0.27) were slightly improved, although there was no statistical significance. Patients with LST decision documentation were less frequently mechanically ventilated (69.8 % vs 80.4 %, P < 0.01) and used fewer inotropes (76.5 % vs 90.1 %, P < 0.01) and more frequent opioids (67.1 % vs 57.4 %, P = 0.04). CONCLUSIONS The legally guided process of LST decision can decrease the CPR rate of children who die in hospitals. This result highlights the possibility of improving end-of-life quality by reducing non-beneficial in-hospital CPR.
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Affiliation(s)
- Jaeyoung Choi
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ah Young Choi
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Esther Park
- Department of Pediatrics, Jeonbuk National University Children's Hospital, Jeonju, Republic of Korea
| | - Meong Hi Son
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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4
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Linebarger JS, Johnson V, Boss RD, Linebarger JS, Collura CA, Humphrey LM, Miller EG, Williams CSP, Rholl E, Ajayi T, Lord B, McCarty CL. Guidance for Pediatric End-of-Life Care. Pediatrics 2022; 149:186860. [PMID: 35490287 DOI: 10.1542/peds.2022-057011] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The final hours, days, and weeks in the life of a child or adolescent with serious illness are stressful for families, pediatricians, and other pediatric caregivers. This clinical report reviews essential elements of pediatric care for these patients and their families, establishing end-of-life care goals, anticipatory counseling about the dying process (expected signs or symptoms, code status, desired location of death), and engagement with palliative and hospice resources. This report also outlines postmortem tasks for the pediatric team, including staff debriefing and bereavement.
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Affiliation(s)
- Jennifer S Linebarger
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri, Kansas City, School of Medicine, Kansas City, Missouri
| | - Victoria Johnson
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Renee D Boss
- Department of Pediatrics, Johns Hopkins University School of Medicine, Berman Institute of Bioethics, Baltimore, Maryland
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5
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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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6
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Bereaved Parent Perspectives on End-of-Life Conversations in Pediatric Oncology. CHILDREN 2022; 9:children9020274. [PMID: 35204993 PMCID: PMC8870516 DOI: 10.3390/children9020274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/03/2022] [Accepted: 02/14/2022] [Indexed: 11/17/2022]
Abstract
Background: Professional education pertaining to end-of-life care with pediatric oncology patients is limited. Pediatric trainees learn about end-of-life conversations largely from the provider’s perspective. Bereaved parents can inform the education of oncologists and the interdisciplinary team by sharing their perceptions and preferences through personal narratives. Methods: The aim of this project was to enhance the healthcare teams’ understanding of bereaved parents’ end-of-life care preferences through narratives. Bereaved parents were recruited from our institution’s Pediatric Supportive Care Committee membership. Parents were tasked with identifying elements of care that were of the greatest importance to them, based upon their personal experiences during their child’s end-of-life care. Narratives were analyzed using standard qualitative methods. Results: Parents of five patients participated, including four mothers and three fathers. Ten themes summarizing essential elements of end-of-life care were identified, including early ongoing and stepwise prognostic disclosure, honoring the child’s voice, support of hope and realism, anticipatory guidance on dying, and continued contact with the bereaved. Conclusion: Bereaved parents emphasize the need for providers to have ongoing honest conversations that support realism and hope that can help them to best prepare for their child’s end of life and to remain in contact with them after death.
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7
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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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8
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Bogetz JF, Revette A, DeCourcey D. Bereaved Parent Perspectives on the Benefits and Burdens of Technology Assistance among Children with Complex Chronic Conditions. J Palliat Med 2022; 25:250-258. [PMID: 34618616 PMCID: PMC8861906 DOI: 10.1089/jpm.2021.0221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Many children with complex chronic conditions (CCCs) are supported by medical technologies. Objective: The aim of this study was to understand bereaved parent perspectives on technology assistance among this unique population. Design: Mixed methods design was used to analyze data from the cross-sectional Survey of Caring for Children with CCCs.Setting/Subjects: Bereaved parents of children with CCCs who received care at a large academic institution in the United States and died between 2006 and 2015. Measurements: Survey items were analyzed descriptively and integrated with thematic analysis of open-response items to identify key themes pertaining to parents' perspectives on technology. Results: 110/211 (52%) parents completed the survey and at least 1 open-response item. More than 60% of parents had children with congenital/chromosomal or central nervous system progressive CCCs, used technology at baseline, and died in the hospital. A subset of parents recalled making decisions either not to initiate (n = 26/101, 26%) or to discontinue (n = 46/104, 44%) technology at end of life. Parents described both the benefits and burdens of technology. Two themes emerged regarding technology's association with the (1) intersection with goals of care and (2) complications and regret. Within goals of care, two subthemes arose: (a) technology was necessary to give time for life extension and/or to say goodbye, and (b) technology greatly impacted the child's quality of life and symptoms. Conclusions: Parents have nuanced perspectives about the benefits and burdens of technology. It is essential to understand parent's most important goals when supporting decisions about technology assistance for children with CCCs.
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Affiliation(s)
- Jori F. Bogetz
- Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA.,Address correspondence to: Jori F. Bogetz, MD, Seattle Children's Research Institute, Center for Clinical and Translational Research, 1900 Ninth Street, JMB-6, Seattle, WA 98101, USA
| | - Anna Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Danielle DeCourcey
- Division of Critical Care, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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9
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Akkermans AA, Lamerichs JMWJJ, Schultz MJM, Cherpanath TGVT, van Woensel JBMJ, van Heerde MM, van Kaam AHLCA, van de Loo MDM, Stiggelbout AMA, Smets EMAE, de Vos MAM. How doctors actually (do not) involve families in decisions to continue or discontinue life-sustaining treatment in neonatal, pediatric, and adult intensive care: A qualitative study. Palliat Med 2021; 35:1865-1877. [PMID: 34176357 PMCID: PMC8637379 DOI: 10.1177/02692163211028079] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Intensive care doctors have to find the right balance between sharing crucial decisions with families of patients on the one hand and not overburdening them on the other hand. This requires a tailored approach instead of a model based approach. AIM To explore how doctors involve families in the decision-making process regarding life-sustaining treatment on the neonatal, pediatric, and adult intensive care. DESIGN Exploratory inductive thematic analysis of 101 audio-recorded conversations. SETTING/PARTICIPANTS One hundred four family members (61% female, 39% male) and 71 doctors (60% female, 40% male) of 36 patients (53% female, 47% male) from the neonatal, pediatric, and adult intensive care of a large university medical center participated. RESULTS We identified eight relevant and distinct communicative behaviors. Doctors' sequential communicative behaviors either reflected consistent approaches-a shared approach or a physician-driven approach-or reflected vacillating between both approaches. Doctors more often displayed a physician-driven or a vacillating approach than a shared approach, especially in the adult intensive care. Doctors did not verify whether their chosen approach matched the families' decision-making preferences. CONCLUSIONS Even though tailoring doctors' communication to families' preferences is advocated, it does not seem to be integrated into actual practice. To allow for true tailoring, doctors' awareness regarding the impact of their communicative behaviors is key. Educational initiatives should focus especially on improving doctors' skills in tactfully exploring families' decision-making preferences and in mutually sharing knowledge, values, and treatment preferences.
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Affiliation(s)
- A Aranka Akkermans
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J M W J Joyce Lamerichs
- Faculty of Humanities, Department of Language, Literature and Communication, VU Amsterdam, Amsterdam, The Netherlands
| | - M J Marcus Schultz
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - T G V Thomas Cherpanath
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J B M Job van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Marc van Heerde
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A H L C Anton van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M D Moniek van de Loo
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A M Anne Stiggelbout
- Medical Decision Making, Department of Biomedical Data Science, Leiden University Medical Center, Leiden, the Netherlands
| | - E M A Ellen Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M A Mirjam de Vos
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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10
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Sawyer KE, Kraft SA, Wightman AG, Clark JD. Pediatric Death by Neurologic Criteria: The Ever-Changing Landscape and the Expanding Role of Palliative Care Professionals. J Pain Symptom Manage 2021; 62:1079-1085. [PMID: 33984463 DOI: 10.1016/j.jpainsymman.2021.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/18/2022]
Abstract
Pediatric palliative care providers are especially suited to support families and medical teams facing a potential diagnosis of brain death, or death by neurologic criteria (DNC), when a child suffers a devastating brain injury. To support pediatric palliative care providers' effectiveness in this role, this article elucidates the clinical determination of DNC and the evolution of the ethical and legal controversies surrounding DNC. Conceptual definitions of death used in the context of DNC have been and continue to be debated amongst academicians, and children's families often have their own concept of death. Increasingly, families have brought legal cases challenging the definition of death, arguing for a right to refuse examination to diagnose DNC, and/or voicing religious objections. We describe these conceptual definitions and legal challenges then explore some potential reasons why families may dispute a determination of DNC. We conclude that working with patients, families, and healthcare providers facing DNC carries inherent and unique challenges suited to intervention by interdisciplinary palliative care teams.
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Affiliation(s)
| | - Stephanie A Kraft
- University of Washington School of Medicine, Seattle Children's Research Institute Seattle, Washington, USA
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11
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Gower WA, Golden SL, King NMP, Nageswaran S. Decision-Making About Tracheostomy for Children With Medical Complexity: Caregiver and Health Care Provider Perspectives. Acad Pediatr 2020; 20:1094-1100. [PMID: 32540425 DOI: 10.1016/j.acap.2020.06.004] [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] [Received: 03/05/2020] [Revised: 05/29/2020] [Accepted: 06/06/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Caregivers of children with medical complexity (CMC) face decisions about tracheostomy. The objectives of this paper are to identify facilitators and barriers to tracheostomy decision-making (TDM) process for CMC. METHODS Using phenomenology as its methodologic orientation, this qualitative study conducted in North Carolina between 2013 and 2015 consists of semistructured interviews with 56 caregivers of 41 CMC who received tracheostomies, and 5 focus groups of 33 health care providers (HCP) at a tertiary care children's hospital involved in TDM for CMC. Participants were asked to share their experiences and perspectives on the TDM process. Qualitative data were transcribed, coded, and organized into themes as is consistent with thematic content analysis. RESULTS Five themes were identified. 1) Caregivers perceived decision about tracheostomy for their children was theirs to make. 2) Strategies that increased caregivers' active participation in the TDM process facilitated the TDM process. 3) Caregiver emotional stress and lack of understanding about tracheostomy were barriers. 4) Good HCP communication during the TDM process was valued; poor communication was a barrier. 5) Collaboration among HCP-facilitated TDM, especially when nurses were involved, whereas fragmentation in care was a barrier. CONCLUSIONS Caregivers take a primary role in the TDM process. Many caregiver and HCP-level facilitators and barriers for TDM exist. Augmenting the facilitators and reducing the barriers identified in this study could improve the TDM process for CMC.
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Affiliation(s)
- William A Gower
- Department of Pediatrics, Wake Forest School of Medicine (WA Gower and S Nageswaran), Winston-Salem, NC; Department of Pediatrics, University of North Carolina School of Medicine (WA Gower), Chapel Hill, NC
| | - Shannon L Golden
- Department of Social Science and Health Policy, Wake Forest University (SL Golden, NMP King, and S Nageswaran), Winston-Salem, NC
| | - Nancy M P King
- Department of Social Science and Health Policy, Wake Forest University (SL Golden, NMP King, and S Nageswaran), Winston-Salem, NC
| | - Savithri Nageswaran
- Department of Pediatrics, Wake Forest School of Medicine (WA Gower and S Nageswaran), Winston-Salem, NC; Department of Social Science and Health Policy, Wake Forest University (SL Golden, NMP King, and S Nageswaran), Winston-Salem, NC.
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12
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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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13
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A Quality Improvement Project to Improve Documentation and Awareness of Limitations of Life-Sustaining Therapies. Pediatr Qual Saf 2020; 5:e304. [PMID: 32607460 PMCID: PMC7297404 DOI: 10.1097/pq9.0000000000000304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/30/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose Poor documentation and understanding of the limitations of life-sustaining therapies upon admission to the pediatric intensive care unit (PICU) can result in moral distress for both providers and families. Limitations of life-sustaining treatments are often not documented and/or understood by members of the health care team. Methods We performed a quality improvement initiative to improve the care teams' understanding and paper documentation of the limitations of life-sustaining therapies in the PICU of a quaternary children's hospital from January 2018 to March 2019. We implemented a series of plan-do-study-act cycles, including initiation of an updated rounding tool that included limitations of interventions, in-person and electronic information sessions, and implementation of a visual bedside tool to remind providers when limitations were present. Pre- and postintervention surveys were administered. Results Nursing paper documentation of limitations of life-sustaining therapies increased sequentially from 0% to 88% during plan-do-study-act cycles. Creating a specific area to document limitations on the nursing sheet resulted in the most significant increase in documentation (36.6 points). Nurses reported that they "always" document limitations, which increased from 10% to 38%. The percentage of nurses who understood patients' intervention limitations increased from 28% to 33%. Conclusions Limitations of life-sustaining therapies in the PICU are nuanced and involve multiple stakeholders. Nursing education and designation of a section of intervention limitations in nursing daily goal paper documentation can increase comfort with therapeutic limitations in the PICU. Future studies should explore impacts on patient care and serve as a framework for the ultimate goal of improving documentation of care limitations and code status in the electronic medical record.
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14
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Steineck A, Wiener L, Mack JW, Shah NN, Summers C, Rosenberg AR. Psychosocial care for children receiving chimeric antigen receptor (CAR) T-cell therapy. Pediatr Blood Cancer 2020; 67:e28249. [PMID: 32159278 PMCID: PMC8396063 DOI: 10.1002/pbc.28249] [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] [Received: 12/20/2019] [Revised: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 12/11/2022]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has transformed the treatment of relapsed/refractory B-cell acute lymphoblastic leukemia (ALL). However, this new paradigm has introduced unique considerations specific to the patients receiving CAR T-cell therapy, including prognostic uncertainty, symptom management, and psychosocial support. With increasing availability, there is a growing need for evidence-based recommendations that address the specific psychosocial needs of the children who receive CAR T-cell therapy and their families. To guide and standardize the psychosocial care offered for patients receiving CAR T-cell therapy, we propose the following recommendations for addressing psychosocial support.
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Affiliation(s)
- Angela Steineck
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, Washington, USA, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA, Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington, USA, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA,Correspondence to: Angela Steineck, MD, Seattle Children’s Research Institute, 4800 Sand Point Way NE, MB 8.501 PO Box 5371, Seattle, WA 98145, Tel: 206-987-2106, Fax: 206-987-3946,
| | - Lori Wiener
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer W. Mack
- Dana Farber Cancer Institute, Boston, MA, USA, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Nirali N. Shah
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Corinne Summers
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, Washington, USA, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Abby R. Rosenberg
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, Washington, USA, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA, Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington, USA, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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15
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Seltzer RR, Raisanen JC, da Silva T, Donohue PK, Williams EP, Shepard J, Boss RD. Medical Decision-Making in Foster Care: Considerations for the Care of Children With Medical Complexity. Acad Pediatr 2020; 20:333-340. [PMID: 31809809 DOI: 10.1016/j.acap.2019.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 11/22/2019] [Accepted: 11/28/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To explore how medical decision-making for children with medical complexity (CMC) occurs in the context of foster care (FC). METHODS Together with a medical FC agency, we identified 15 CMC in medical FC and recruited eligible care team members (biological and foster parents, medical FC nurses, caseworkers in medical FC/child welfare, and pediatricians) for each child. Semistructured interviews were conducted, and conventional content analysis was applied to transcripts. RESULTS Fifty-eight interviews were completed with 2-5 care team members/child. Serious decision-making related to surgeries and medical technology was common. Themes regarding medical decision-making for CMC in FC emerged: 1) Protocol: decision-making authority is dictated by court order and seriousness of decision, 2) Process: decision-making is dispersed among many team members, 3) Representing the child's interests: the majority of respondents stated that the foster parent represents the child's best interests, while the child welfare agency should have legal decision-making authority, and 4) Perceived barriers: serious medical decision-making authority is often given to individuals who spend little time with the child. CONCLUSIONS Medical decisions for CMC can have uncertain risk/benefit ratios. For CMC in FC, many individuals have roles in these nuanced decisions; those with ultimate decision-making authority may have minimal interaction with the child. Pediatricians can assist by clarifying who has legal decision-making authority, facilitating team communication to promote truly informed consent, and serving as a resource to decision-makers. Further research should explore how to adapt the traditional model of shared decision-making to meet the needs of this population.
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Affiliation(s)
- Rebecca R Seltzer
- Johns Hopkins University School of Medicine (RR Seltzer, PK Donohue, J Shepard, RD Boss), Baltimore, Md; Berman Institute of Bioethics (RR Seltzer, JC Raisanen, RD Boss), Baltimore, Md.
| | - Jessica C Raisanen
- Berman Institute of Bioethics (RR Seltzer, JC Raisanen, RD Boss), Baltimore, Md
| | - Trisha da Silva
- Johns Hopkins Bloomberg School of Public Health (T da Silva, PK Donohue), Baltimore, Md
| | - Pamela K Donohue
- Johns Hopkins University School of Medicine (RR Seltzer, PK Donohue, J Shepard, RD Boss), Baltimore, Md; Johns Hopkins Bloomberg School of Public Health (T da Silva, PK Donohue), Baltimore, Md
| | - Erin P Williams
- Columbia University Vagelos College of Physicians and Surgeons (EP Williams), New York, NY
| | - Jennifer Shepard
- Johns Hopkins University School of Medicine (RR Seltzer, PK Donohue, J Shepard, RD Boss), Baltimore, Md
| | - Renee D Boss
- Johns Hopkins University School of Medicine (RR Seltzer, PK Donohue, J Shepard, RD Boss), Baltimore, Md; Berman Institute of Bioethics (RR Seltzer, JC Raisanen, RD Boss), Baltimore, Md
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16
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Menon AP, Mok YH, Loh LE, Lee JH. Pediatric Palliative Transport in Critically Ill Children: A Single Center's Experience and Parents' Perspectives. J Pediatr Intensive Care 2019; 9:99-105. [PMID: 32351763 DOI: 10.1055/s-0039-3401009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/03/2019] [Indexed: 12/29/2022] Open
Abstract
The transfer of critically ill children from intensive care units (ICUs) to their homes for palliation is seldom described. We report our 10-year pediatric palliative transport experience and conducted a survey to gain parents' perspectives of their child's transport experience. Over the study period, eight patients were transported from our pediatric ICU to their homes or hospice facilities. There were no intratransport adverse events. Parents who participated in the survey responded positively to the transport experience. The availability of a dedicated critical care transport service allowed for palliative transfers to be performed safely. Facilitating transport to allow withdrawal of life support at home is an acceptable option to families as part of holistic end-of-life care.
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Affiliation(s)
- Anuradha P Menon
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Lik Eng Loh
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
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17
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Parham D, Reed D, Olicker A, Parrill F, Sharma J, Brunkhorst J, Noel-MacDonnell J, Voos K. Families as educators: a family-centered approach to teaching communication skills to neonatology fellows. J Perinatol 2019; 39:1392-1398. [PMID: 31371832 DOI: 10.1038/s41372-019-0441-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 06/10/2019] [Accepted: 06/17/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine whether the use of family members as educators in a structured educational intervention would increase neonatology fellows' confidence in performing core communication skills targeted to guide family decision-making. STUDY DESIGN Neonatology fellows at two centers participated in simulation-based training utilizing formally trained family members of former patients. Fellows completed self-assessment surveys before participating, immediately following participation, and 1-month following the training. Family members also evaluated fellow communication. RESULTS For each core competency assessed, there was a statistically significant increase in self-perceived preparedness from pre-course to post-course assessments. Fellows additionally endorsed using skills learned in the curriculum in daily clinical practice. Family educators rated fellow communication highest in empathetic listening and nonverbal communication. CONCLUSIONS Participation in a communication skills curriculum utilizing formally trained family members as educators for medical trainees successfully increased fellows' self-perceived preparedness in selected core competencies in communication. Family educators provided useful, generalizable feedback.
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Affiliation(s)
- Danielle Parham
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA. .,Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA. .,Division of Neonatology, University Hospitals Cleveland Medical Center Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
| | - Danielle Reed
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Arielle Olicker
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Neonatology, University Hospitals Cleveland Medical Center Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Fey Parrill
- Department of Cognitive Science, Case Western Reserve University, Cleveland, OH, USA
| | - Jotishna Sharma
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Jessica Brunkhorst
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Janelle Noel-MacDonnell
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, MO, USA
| | - Kristin Voos
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Neonatology, University Hospitals Cleveland Medical Center Rainbow Babies and Children's Hospital, Cleveland, OH, USA.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
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18
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Sochet AA, Nakagawa TA. Trust the Internet or Trust Your Physician: Public Perception of Brain Death Isn't a No Brainer. Chest 2019; 154:238-239. [PMID: 30080498 DOI: 10.1016/j.chest.2018.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Anthony A Sochet
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Thomas A Nakagawa
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care, Johns Hopkins All Children's Hospital, St. Petersburg, FL.
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19
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Constantinou G, Garcia R, Cook E, Randhawa G. Children's unmet palliative care needs: a scoping review of parents' perspectives. BMJ Support Palliat Care 2019; 9:439-450. [PMID: 31324615 DOI: 10.1136/bmjspcare-2018-001705] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 05/15/2019] [Accepted: 05/29/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Children with life-limiting conditions often have complex needs, making it challenging for services to provide satisfactory care. Few studies consider whether services actually meet families' needs by exploring and identifying the parents' perspectives of unmet needs. AIM To identify what published evidence is available on the unmet needs of children with life-limiting conditions and their families, from the perspective of parents, internationally. ELIGIBILITY CRITERIA: Inclusion criteria: papers from the perspective of parents of children aged 0-19 years, who have a life-limiting condition and are receiving palliative care. Exclusion criteria: those papers not written in English, not reporting primary research and discussing children who died from stillbirth, accidental or unexpected circumstance. CHARTING METHODS A scoping review was conducted in accordance with the methods of Arksey and O'Malley. SOURCES OF EVIDENCE The electronic databases PubMed, MEDLINE, CINAHL and PsycINFO were searched. Key terms included: parent, needs, met/unmet/satisfaction, palliative/supportive/end of life care, life-limiting/life-threatening illness, infants/children/young people. RESULTS Total hit indicated 5975 papers for screening. Fifty-five papers met the scoping review criteria. The majority used mixed-methods approaches inclusive of: questionnaires, self-report measures, in-depth interviews, focus groups, case record analysis and art-based workshops. Unmet needs included: respite care, coordination and organisation of care, psychological support and professional communication skills. CONCLUSIONS The findings suggest many unmet needs from the parent's perspective, across several aspects of the Quality Standards and Children's Palliative Care Frameworks. Further research is needed which explores the parent's unmet needs in palliative care services.
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Affiliation(s)
| | | | - Erica Cook
- Institute for Health Research, University of Bedfordshire, Luton, UK
| | - Gurch Randhawa
- Institute for Health Research, University of Bedfordshire, Luton, UK
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20
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Lockwood B, Humphrey L. Supporting Children and Families at a Child's End of Life: Pediatric Palliative Care Pearls of Anticipatory Guidance for Families. Child Adolesc Psychiatr Clin N Am 2018; 27:527-537. [PMID: 30219215 DOI: 10.1016/j.chc.2018.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Mental health professionals can play a key role in helping pediatric patients and their families prepare for and endure the death of a child. Impactful interventions include assisting a family's transition toward acceptance of a child's pending death, using prognostication as a tool in emotional preparedness, and education on expectant symptoms to optimize management and sense of caregiver efficacy.
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Affiliation(s)
- Bethany Lockwood
- Division of Palliative Medicine, The Ohio State University College of Medicine, McCampbell Hall, 5th Floor, 1581 Dodd Drive, Columbus, OH 43210, USA.
| | - Lisa Humphrey
- Hospice and Palliative Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, A1055, Columbus, OH 43205, USA
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21
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Short SR, Thienprayoon R. Pediatric palliative care in the intensive care unit and questions of quality: a review of the determinants and mechanisms of high-quality palliative care in the pediatric intensive care unit (PICU). Transl Pediatr 2018; 7:326-343. [PMID: 30460185 PMCID: PMC6212394 DOI: 10.21037/tp.2018.09.11] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This article reviews the state and practice of pediatric palliative care (PC) within the pediatric intensive care unit (PICU) with specific consideration of quality issues. This includes defining PC and end of life (EOL) care. We will also describe PC as it pertains to alleviating children's suffering through the provision of "concurrent care" in the ICU environment. Modes of care, and attendant strengths, of both the consultant and integrated models will be presented. We will review salient issues related to the provision of PC in the PICU, barriers to optimal practice, parental, and staff perceptions. Opportunity areas for quality improvement and the role of initiatives and measures such as education, family-based initiatives, staff needs, symptom recognition, grief, and communication follow. To conclude, we will look to the literature for PC resources for pediatric intensivists and future directions of study.
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22
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Marsac ML, Kindler C, Weiss D, Ragsdale L. Let's Talk About It: Supporting Family Communication during End-of-Life Care of Pediatric Patients. J Palliat Med 2018; 21:862-878. [PMID: 29775556 DOI: 10.1089/jpm.2017.0307] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Communication is key in optimizing medical care when a child is approaching end of life (EOL). Research is yet to establish best practices for how medical teams can guide intrafamily communication (including surviving siblings) when EOL care is underway or anticipated for a pediatric patient. While recommendations regarding how medical teams can facilitate communication between the medical team and the family exist, various barriers may prevent the implementation of these recommendations. OBJECTIVE This review aims to provide a summary of research-to-date on family and medical provider perceptions of communication during pediatric EOL care. DESIGN Systematic review. RESULTS Findings from a review of 65 studies suggest that when a child enters EOL care, many parents try to protect their child and/or themselves by avoiding discussions about death. Despite current recommendations, medical teams often refrain from discussing EOL care with pediatric patients until death is imminent for a variety of reasons (e.g., family factors and discomfort with EOL conversations). Parents consistently report a need for honest complete information, delivered with sensitivity. Pediatric patients often report a preference to be informed of their prognosis, and siblings express a desire to be involved in EOL discussions. CONCLUSIONS Families may benefit from enhanced communication around EOL planning, both within the family and between the family and medical team. Future research should investigate a potential role for medical teams in supporting intrafamily communication about EOL challenges and should examine how communication between medical teams and families can be facilitated as EOL approaches.
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Affiliation(s)
- Meghan L Marsac
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky.,2 College of Medicine, University of Kentucky , Lexington, Kentucky
| | - Christine Kindler
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky
| | - Danielle Weiss
- 3 Department of Pediatrics, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Lindsay Ragsdale
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky.,2 College of Medicine, University of Kentucky , Lexington, Kentucky
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23
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Butler AE, Hall H, Copnell B. Becoming a Team: The Nature of the Parent-Healthcare Provider Relationship when a Child is Dying in the Pediatric Intensive Care Unit. J Pediatr Nurs 2018; 40:e26-e32. [PMID: 29454506 DOI: 10.1016/j.pedn.2018.02.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To explore bereaved parents' perspectives of parent and staff roles in the pediatric intensive care unit when their child was dying, and their relationships with healthcare staff during this time. DESIGN AND METHODS Constructivist grounded theory was used to undertake this study. Semi-structured interviewers were conducted with 26 bereaved parents recruited from four Australian pediatric intensive care units. The constant comparative method, coupled with open, focused, and theoretical coding were used for data analysis. RESULTS Becoming a team explores the changes that occurred to the parent-healthcare provider relationship when parents realized their child was dying and attempted to become part of their child's care team. When the focus of care changed from 'life-saving' to 'end-of-life', parents' perspectives and desires of their and the healthcare providers' roles changed. Parents' attempted to reconstruct their roles to match their changing perspectives, which may or may not have been successful, depending on their ability to successfully negotiate these roles with healthcare providers. CONCLUSIONS Findings offer insights into parental understandings of both the parental and healthcare provider roles for parents of dying children in intensive care, and the ways in which the parent-healthcare provider relationships can influence and be influenced by changes to these roles. PRACTICE IMPLICATIONS Successful parent-healthcare provider relationships require an understanding of the parental and healthcare provider role from the parents' perspective. The meanings of the parental and healthcare provider roles should be explored with parents of dying children, and supported as much as possible to enable the development of a collaborative relationship.
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Affiliation(s)
- Ashleigh E Butler
- School of Nursing and Midwifery, Monash University, Clayton Campus, Wellington Road, Victoria 3800, Australia; Adult and Pediatric Intensive Care Unit, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia.
| | - Helen Hall
- School of Nursing and Midwifery, Monash University, Clayton Campus, Wellington Road, Victoria 3800, Australia
| | - Beverley Copnell
- School of Nursing and Midwifery, Monash University, Clayton Campus, Wellington Road, Victoria 3800, Australia
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25
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Postier A, Catrine K, Remke S. Interdisciplinary Pediatric Palliative Care Team Involvement in Compassionate Extubation at Home: From Shared Decision-Making to Bereavement. CHILDREN-BASEL 2018. [PMID: 29518983 PMCID: PMC5867496 DOI: 10.3390/children5030037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Little is known about the role of pediatric palliative care (PPC) programs in providing support for home compassionate extubation (HCE) when families choose to spend their child’s end of life at home. Two cases are presented that highlight the ways in which the involvement of PPC teams can help to make the option available, help ensure continuity of family-centered care between hospital and home, and promote the availability of psychosocial support for the child and their entire family, health care team members, and community. Though several challenges to realizing the option of HCE exist, early consultation with a PPC team in the hospital, the development of strategic community partnerships, early referral to home based care resources, and timely discussion of family preferences may help to make this option a realistic one for more families. The cases presented here demonstrate how families’ wishes with respect to how and where their child dies can be offered, even in the face of challenges. By joining together when sustaining life support may not be in the child’s best interest, PPC teams can pull together hospital and community resources to empower families to make decisions about when and where their child dies.
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Affiliation(s)
- Andrea Postier
- Pain Medicine, Palliative Care and Integrative Medicine Program, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404, USA.
| | - Kris Catrine
- Pain Medicine, Palliative Care and Integrative Medicine Program, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404, USA.
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55404, USA.
| | - Stacy Remke
- School of Social Work, University of Minnesota, Saint Paul, MN 55404, USA.
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Zaal-Schuller IH, Willems DL, Ewals FVPM, van Goudoever JB, de Vos MA. Considering quality of life in end-of-life decisions for severely disabled children. RESEARCH IN DEVELOPMENTAL DISABILITIES 2018; 73:67-75. [PMID: 29268163 DOI: 10.1016/j.ridd.2017.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 12/08/2017] [Accepted: 12/11/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND End-of-life decisions (EoLDs) are very difficult to make. How parents and physicians incorporate quality of life (QoL) considerations into their end-of-life decision making (EoLDM) for children with profound intellectual and multiple disabilities (PIMD) remains unknown. AIMS To determine which elements contribute to QoL according to parents and physicians, how QoL is incorporated into EoLDM and how parents and physicians discuss QoL considerations in the Netherlands. METHODS Semi-structured interviews were conducted with the physicians and parents of 14 children with PIMD for whom an EoLD had been made within the past two years. RESULTS Parents and physicians agreed on the main elements that contribute to QoL in children with PIMD. The way in which QoL was incorporated differed slightly for different types of decisions. Parents and physicians rarely discussed elements contributing to the child's QoL when making EoLDS. CONCLUSIONS and Implications Although QoL was highly important during EoLDM for children with PIMD, parents and physicians did not fully explore the elements that contribute to the child's QoL when they made EoLDs. We recommend the development of a communication tool that will help parents and physicians discuss elements that contribute to QoL and the consequences these elements have for upcoming decisions.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital, Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Kaye EC, Snaman JM, Johnson L, Levine D, Powell B, Love A, Smith J, Ehrentraut JH, Lyman J, Cunningham M, Baker JN. Communication with Children with Cancer and Their Families Throughout the Illness Journey and at the End of Life. PALLIATIVE CARE IN PEDIATRIC ONCOLOGY 2018. [DOI: 10.1007/978-3-319-61391-8_4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Alrimawi I, Saifan AR, Abdelkader R, Batiha AM. Palestinian community perceptions of do-not-resuscitation order for terminally Ill patients: A qualitative study. J Clin Nurs 2017; 27:2719-2728. [PMID: 28557015 DOI: 10.1111/jocn.13905] [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] [Accepted: 05/25/2017] [Indexed: 12/21/2022]
Abstract
AIM AND OBJECTIVES To illustrate the Palestinian community's views, opinions and stances about the concept of do-not-resuscitate for terminally ill patients. BACKGROUND Do-not-resuscitate orders are practised in many countries worldwide, but there is no consensus on their practice in the Middle East. Do-not-resuscitate orders may be applied for terminally ill paediatric patients. Some studies have been conducted describing people's experiences with these do-not-resuscitate orders. However, few studies have considered community perspectives on do-not-resuscitate orders for terminally ill patients in Palestine. DESIGN A descriptive-qualitative design was adopted. METHODS A purposive sample of 24 participants was interviewed, with consideration of demographical characteristics such as age, gender, education and place of residency. The participants were recruited over a period of 6 months. Individual semistructured interviews were utilised. These interviews were transcribed and analysed using thematic analysis. FINDINGS Significantly, the majority of the participants did not know the meaning of do-not-resuscitate and thought that removal of life-sustaining devices and do-not-resuscitate were the same concept. Most of the interviewees adopted stances against do-not-resuscitate orders. Several factors were suggested to influence the decision of accepting or rejecting the do-not-resuscitate order. The majority of the participants mentioned religion as a major factor in forming their viewpoints. The participants expressed different views regarding issuing a law regarding do-not-resuscitate orders. CONCLUSION Our findings provide a unique understanding that there is a general misunderstanding among our participants regarding the do-not-resuscitate order. Further research with policymakers and stakeholders is still required.
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Affiliation(s)
| | | | - Raghad Abdelkader
- School of Nursing, Applied Science Private University, Amman, Jordan
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Butler AE, Copnell B, Hall H. Welcoming expertise: Bereaved parents' perceptions of the parent-healthcare provider relationship when a critically ill child is admitted to the paediatric intensive care unit. Aust Crit Care 2017; 32:34-39. [PMID: 29153961 DOI: 10.1016/j.aucc.2017.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/18/2017] [Accepted: 09/22/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Entering the paediatric intensive care unit with a critically ill child is a stressful experience for parents. In addition to fearing for their child's well-being, parents must navigate both a challenging environment and numerous new relationships with healthcare staff. How parents form relationships with staff and how they perceive both their own and the healthcare providers' roles in this early stage of their paediatric intensive care journey is currently unknown. PURPOSE This paper explores bereaved parents' perceptions of their role and their relationships with healthcare providers when their child is admitted to the intensive care unit, as part of a larger study exploring their experiences when their child dies in intensive care. METHODS A constructivist grounded theory approach was utilised to recruit 26 bereaved parents from 4 Australian intensive care units. Parents participated in audio-recorded, semi-structured interviews lasting 90-150min. All data were analysed using the constant comparative analysis processes, supported by theoretical memos. RESULTS Upon admission, parents viewed healthcare providers as experts, both of their child's medical care and of the hospital system. This expertise was welcomed, with the parent-healthcare provider relationship developing around the child's need for medical care. Parents engaged in 2 key behaviours in their relationships with staff: prioritising survival, and learning 'the system'. Within each of these behaviours are several subcategories, including 'Stepping back', 'Accepting restrictions' and 'Deferring to medical advice'. CONCLUSIONS The relationships between parents and staff shift and change across the child's admission and subsequent death in the paediatric intensive care unit. However, upon admission, this relationship centres around the child's potential survival and their need for medical care, and the parent's recognition of the healthcare staff as experts of both the child's care and the hospital system.
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Affiliation(s)
- Ashleigh E Butler
- School of Nursing and Midwifery, Monash University, Victoria, Australia; Adult and Paediatric Intensive Care Unit, Monash Health, Victoria, Australia.
| | - Beverley Copnell
- School of Nursing and Midwifery, Monash University, Victoria, Australia.
| | - Helen Hall
- School of Nursing and Midwifery, Monash University, Victoria, Australia.
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Caring for Long Length of Stay Patients in the Neonatal ICU and PICU: How Do We Ensure Coherent Decisions When the Physicians Are Continuously Rotating? Pediatr Crit Care Med 2017; 18:907-908. [PMID: 28863097 DOI: 10.1097/pcc.0000000000001260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Professional Responsibility, Consensus, and Conflict: A Survey of Physician Decisions for the Chronically Critically Ill in Neonatal and Pediatric Intensive Care Units. Pediatr Crit Care Med 2017; 18:e415-e422. [PMID: 28658198 DOI: 10.1097/pcc.0000000000001247] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe neonatologist and pediatric intensivist attitudes and practices relevant to high-stakes decisions for children with chronic critical illness, with particular attention to physician perception of professional duty to seek treatment team consensus and to disclose team conflict. DESIGN Self-administered online survey. SETTING U.S. neonatal ICUs and PICUs. SUBJECTS Neonatologists and pediatric intensivists. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We received 652 responses (333 neonatologists, denominator unknown; 319 of 1,290 pediatric intensivists). When asked about guiding a decision for tracheostomy in a chronically critically ill infant, only 41.7% of physicians indicated professional responsibility to seek a consensus decision, but 73.3% reported, in practice, that they would seek consensus and make a consensus-based recommendation; the second most common practice (15.5%) was to defer to families without making recommendations. When presented with conflict among the treatment team, 63% of physicians indicated a responsibility to be transparent about the decision-making process and reported matching practices. Neonatologists more frequently reported a responsibility to give decision making fully over to families; intensivists were more likely to seek out consensus among the treatment team. CONCLUSIONS ICU physicians do not agree about their responsibilities when approaching difficult decisions for chronically critically ill children. Although most physicians feel a professional responsibility to provide personal recommendations or defer to families, most physicians report offering consensus recommendations. Nearly all physicians embrace a sense of responsibility to disclose disagreement to families. More research is needed to understand physician responsibilities for making recommendations in the care of chronically critically ill children.
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Butler AE, Hall H, Copnell B. The changing nature of relationships between parents and healthcare providers when a child dies in the paediatric intensive care unit. J Adv Nurs 2017; 74:89-99. [DOI: 10.1111/jan.13401] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ashleigh E. Butler
- School of Nursing and Midwifery; Monash University; Clayton Vic. Australia
| | - Helen Hall
- School of Nursing and Midwifery; Monash University; Clayton Vic. Australia
| | - Beverley Copnell
- School of Nursing and Midwifery; Monash University; Clayton Vic. Australia
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Abstract
Pain management in the neonatal ICU remains challenging for many clinicians and in many complex care circumstances. The authors review general pain management principles and address the use of pain scales, non-pharmacologic management, and various agents that may be useful in general neonatal practice, procedurally, or at the end of life. Chronic pain and neonatal abstinence are also noted.
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Affiliation(s)
- Brian S Carter
- Department of Pediatrics, Division of Neonatology, University of Missouri at Kansas City School of Medicine, 2401 Gillham Rd, Kansas City, MO 64108; Children׳s Mercy Bioethics Center, Kansas City, MO.
| | - Jessica Brunkhorst
- Department of Pediatrics, Division of Neonatology, University of Missouri at Kansas City School of Medicine, 2401 Gillham Rd, Kansas City, MO 64108
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Wangmo T, De Clercq E, Ruhe KM, Beck-Popovic M, Rischewski J, Angst R, Ansari M, Elger BS. Better to know than to imagine: Including children in their health care. AJOB Empir Bioeth 2017; 8:11-20. [PMID: 28949869 DOI: 10.1080/23294515.2016.1207724] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND This article describes the overall attitudes of children, their parents, and attending physicians toward including or excluding pediatric patients in medical communication and health care decision-making processes. METHODS Fifty-two interviews were carried out with pediatric patients (n = 17), their parents (n = 19), and attending oncologists (n = 16) in eight Swiss pediatric oncology centers. The interviews were analyzed using thematic coding. RESULTS Parenting styles, the child's personality, and maturity are factors that have a great impact upon the inclusion of children in their health care processes. Children reported the desire to be heard and involved, but they did not want to dominate the decision-making process. Ensuring trust in the parent-child and physician-patient relationships and respecting the child as the affected person were important values determining children's involvement. These two considerations were closely connected with the concern that fantasies are often worse than reality. Seeking children's compliance with treatment was a practical but critical reason for informing them about their health care. The urge to protect them from upsetting news sometimes resulted in their (partial) exclusion. CONCLUSIONS The ethical imperative for inclusion of children in their health care choices was not so much determined by the right for self-determination, but by the need to include them. If children are excluded, they imagine things, become more isolated, and are left alone with their fears. Nevertheless, the urge to protect children is innate, as adults often underestimate children's coping capacities.
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Zaal-Schuller IH, Willems DL, Ewals FVPM, van Goudoever JB, de Vos MA. How parents and physicians experience end-of-life decision-making for children with profound intellectual and multiple disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 59:283-293. [PMID: 27665411 DOI: 10.1016/j.ridd.2016.09.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/28/2016] [Accepted: 09/15/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND End-of-life decisions (EoLD) often concern children with profound intellectual and multiple disabilities (PIMD). Yet, little is known about how parents and physicians discuss and make these decisions. AIMS The objective of this research was to investigate the experiences of the parents and the involved physician during the end-of-life decision-making (EoLDM) process for children with PIMD. METHODS In a retrospective, qualitative study, we conducted semi-structured interviews with the physicians and parents of 14 children with PIMD for whom an EoLD was made within the past two years. RESULTS A long-lasting relationship appeared to facilitate the EoLDM process, although previous negative healthcare encounters could also lead to distrust. Parents and physicians encountered disagreements during the EoLDM process, but these disagreements could also improve the decision-making process. Most parents, as well as most physicians, considered the parents to be the experts on their child. In making an EoLD, both parents and physicians preferred a shared decision-making approach, although they differed in what they actually meant by this concept. CONCLUSION The EoLDM process for children with PIMD can be improved if physicians are more aware of the specific situation and of the roles and expectations of the parents of children with PIMD.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital - Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Boss RD. Palliative care for extremely premature infants and their families. ACTA ACUST UNITED AC 2016; 16:296-301. [PMID: 25708072 DOI: 10.1002/ddrr.123] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Accepted: 04/24/2011] [Indexed: 11/11/2022]
Abstract
Extremely premature infants face multiple acute and chronic life-threatening conditions. In addition, the treatments to ameliorate or cure these conditions often entail pain and discomfort. Integrating palliative care from the moment that extremely premature labor is diagnosed offers families and clinicians support through the process of defining goals of care and making decisions about life support. For both the extremely premature infant who dies soon after birth and the extremely premature infant who experiences multiple complications over weeks and months in the neonatal intensive care unit, palliative care can maintain a focus on infant comfort and family support. This article highlights the ways in which palliative care can be incorporated into intensive care for all critically ill infants.
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Affiliation(s)
- Renee D Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine and Berman Institute of Bioethics, Baltimore, Maryland.
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October TW, Hinds PS, Wang J, Dizon ZB, Cheng YI, Roter DL. Parent Satisfaction With Communication Is Associated With Physician's Patient-Centered Communication Patterns During Family Conferences. Pediatr Crit Care Med 2016; 17:490-7. [PMID: 27058750 PMCID: PMC4893980 DOI: 10.1097/pcc.0000000000000719] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the association between physician's patient-centered communication patterns and parental satisfaction during decision-making family conferences in the PICU. DESIGN Single-site, cross-sectional study. SETTING Forty-four-bed PICUs in a free-standing children's hospital. PARTICIPANTS Sixty-seven English-speaking parents of 39 children who participated in an audiorecorded family conference with 11 critical care attending physicians. MEASUREMENTS AND MAIN RESULTS Thirty-nine family conferences were audiorecorded. Sixty-seven of 77 (92%) eligible parents were enrolled. The conference recordings were coded using the Roter Interaction Analysis System and a Roter Interaction Analysis System-based patient-centeredness score, which quantitatively evaluates the conversations for physician verbal dominance and discussion of psychosocial elements, such as a family's goals and preferences. Higher patient-centeredness scores reflect higher proportionate dialogue focused on psychosocial, lifestyle, and socioemotional topics relative to medically focused talk. Parents completed satisfaction surveys within 24 hours of the conference. Conferences averaged 45 minutes in length (SD, 19 min), during which the medical team contributed 73% of the dialogue compared with parental contribution of 27%. Physicians dominated the medical team, contributing 89% of the team contribution to the dialogue. The majority of physician speech was medically focused (79%). A patient-centeredness score more than 0.75 predicted parental satisfaction (β = 12.05; p < 0.0001), controlling for the length of conference, child severity of illness, parent race, and socioeconomic status. Parent satisfaction was negatively influenced by severity of illness of the patient (β = -4.34; p = 0.0003), controlling for previously mentioned factors in the model. CONCLUSIONS Parent-physician interactions with more patient-centered elements, such as increased proportions of empathetic statements, question asking, and emotional talk, positively influence parent satisfaction despite the child's severity of illness.
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Affiliation(s)
- Tessie W October
- 1Department of Critical Care Medicine, Children's National Health Systems, Washington, DC. 2Department of Pediatrics, George Washington University School of Medicine, Washington, DC. 3Department of Nursing Research and Quality Outcomes, Children's National Health Systems, Washington, DC. 4Center for Translational Science, Department of Pediatrics, Children's National Health Systems, Washington, DC. 5Department of Epidemiology and Biostatistics, George Washington University School of Medicine, Washington, DC. 6Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Sankaran K, Hedin E, Hodgson-Viden H. Neonatal end of life care in a tertiary care centre in Canada: a brief report. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:379-385. [PMID: 27165583 PMCID: PMC7390367 DOI: 10.7499/j.issn.1008-8830.2016.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To describe the processes followed by a neonatal team engaging parents with respect to end of life care of babies in whom long term survival was negligible or impossible; and to describe feedback from these parents after death of their child. METHODS A retrospective review was conducted of health records of neonates who had died receiving palliative care over a period of 5 years at a tertiary neonatal centre. Specific inclusion criteria were determined in advance that identified care given by a dedicated group of caregivers. RESULTS Thirty infants met eligibility criteria. After excluding one outlier an average of 4 discussions occurred with families before an end of life decision was arrived at. Switching from aggressive care to comfort care was a more common decision-making route than having palliative care from the outset. Ninety per cent of families indicated satisfaction with the decision making process at follow-up and more than half of them returned later to meet with the NICU team. Some concerns were expressed about the availability of neonatologists at weekends. CONCLUSIONS A compassionate and humane approach to the family with honesty and empathy creates a positive environment for decision-making. An available, experienced team willing to engage families repeatedly is beneficial. Initiating intensive care with subsequent palliative care is acceptable to families and caregivers.
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Affiliation(s)
- Koravangattu Sankaran
- Division of Neonatology, Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Canada
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Sanderson A, Hall AM, Wolfe J. Advance Care Discussions: Pediatric Clinician Preparedness and Practices. J Pain Symptom Manage 2016; 51:520-8. [PMID: 26550935 DOI: 10.1016/j.jpainsymman.2015.10.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 10/26/2015] [Accepted: 10/28/2015] [Indexed: 11/30/2022]
Abstract
CONTEXT Few data exist regarding clinician preparedness to participate in advance care discussions (ACD) and the practices surrounding these discussions for children with life-threatening conditions. OBJECTIVES We sought to understand pediatric clinician preparedness to participate in ACD and the practices surrounding these discussions. METHODS A survey was administered to assess clinician attitudes and behaviors regarding ACD. RESULTS Two hundred sixty-six clinicians (107 physicians and 159 nurses) responded to the survey (response rate 53.6%). Seventy-five percent of clinicians felt prepared to participate in ACD. Most clinicians believed they were prepared to express empathy (98.8%), discuss goals of care for an adolescent patient (90.3%), and elicit a parent's hopes (90.3%). Conversely, several felt unprepared to discuss resuscitation status with school-aged (59.7%) and adolescent (48.5%) patients and to conduct a family conference (39.5%). The most frequent topics addressed were: parents' understanding of the patient's illness (75.5%), primary goals of the parent (75.1%), and the parents' understanding of prognosis (71.1%). Conversely, the topics least commonly discussed were as follows: belief system of the patient/family (22.0%), patient's hopes (21.2%), and the patient's perceptions of his/her quality of life (19.8%). Notably, 40% of clinicians believe that caring for patients with poor prognoses is depressing, and this was more common among less-experienced clinicians (P = 0.048). CONCLUSION Many clinicians believe they are prepared to participate in ACD, but practices are not consistent with expert recommendations for optimal ACD. Educational interventions aimed at improving clinician knowledge, attitudes, and behavior, and greater clinician support may enhance health care provider ACD preparedness and skills.
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Affiliation(s)
- Amy Sanderson
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Amber M Hall
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joanne Wolfe
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; Division of Pediatric Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Foster M, Whitehead L, Maybee P. The Parents', Hospitalized Child's, and Health Care Providers' Perceptions and Experiences of Family-Centered Care Within a Pediatric Critical Care Setting: A Synthesis of Quantitative Research. JOURNAL OF FAMILY NURSING 2016; 22:6-73. [PMID: 26706128 DOI: 10.1177/1074840715618193] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Family-centered care (FCC) purports that unlimited presence and involvement of the family in the care of the hospitalized child will optimize the best outcome for the child, family, and institution. A systematic appraisal was conducted of peer-reviewed, English-language, primary quantitative research conducted within a pediatric critical care setting reported from 1998 to 2014. The aim of this review was to explore the parents', hospitalized child's, and health care providers' perception of FCC within pediatric critical care. Fifty-nine articles met the criteria that generated themes of stress, communication, and parents' and children's needs. This review highlighted that communication tailored to meet the parents' and child's needs is the key to facilitating FCC and positive health outcomes. Health care providers need to be available to provide clinical expertise and support throughout the health care journey. Future initiatives, education, and research are needed to evaluate the benefits of parent- and child-led FCC practice.
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Affiliation(s)
- Mandie Foster
- 1 University of Otago, Christchurch, New Zealand
- 2 Christchurch Hospital, New Zealand
| | - Lisa Whitehead
- 3 Edith Cowan University, Joondalup, Western Australia, Australia
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Zaal-Schuller IH, de Vos MA, Ewals FVPM, van Goudoever JB, Willems DL. End-of-life decision-making for children with severe developmental disabilities: The parental perspective. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 49-50:235-246. [PMID: 26741261 DOI: 10.1016/j.ridd.2015.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 11/28/2015] [Accepted: 12/08/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND AIMS The objectives of this integrative review were to understand how parents of children with severe developmental disorders experience their involvement in end-of-life decision-making, how they prefer to be involved and what factors influence their decisions. METHODS AND PROCEDURES We searched MEDLINE, EMBASE, CINAHL and PsycINFO. The search was limited to articles in English or Dutch published between January 2004 and August 2014. We included qualitative and quantitative original studies that directly investigated the experiences of parents of children aged 0-18 years with severe developmental disorders for whom an end-of-life decision had been considered or made. OUTCOMES AND RESULTS We identified nine studies that met all inclusion criteria. Reportedly, parental involvement in end-of-life decision-making varied widely, ranging from having no involvement to being the sole decision-maker. Most parents preferred to actively share in the decision-making process regardless of their child's specific diagnosis or comorbidity. The main factors that influenced parents in their decision-making were: their strong urge to advocate for their child's best interests and to make the best (possible) decision. In addition, parents felt influenced by their child's visible suffering, remaining quality of life and the will they perceived in their child to survive. CONCLUSIONS AND IMPLICATIONS Most parents of children with severe developmental disorders wish to actively share in the end-of-life decision-making process. An important emerging factor in this process is the parents' feeling that they have to stand up for their child's interests in conversations with the medical team.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital-Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Nicholas DB, Beaune L, Barrera M, Blumberg J, Belletrutti M. Examining the Experiences of Fathers of Children with a Life-Limiting Illness. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2016; 12:126-144. [PMID: 27143577 DOI: 10.1080/15524256.2016.1156601] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Families who have a child diagnosed with a life-limiting illness (LLI) face substantial challenges resulting from the complexity and devastating impact of the condition and potential closeness of death. The experiences of fathers of a child with LLI have been understudied; therefore, this study explored the stresses, experiences, and strategies of these fathers, including their perceptions about support needs. Based on grounded theory, in-depth semi-structured interviews were conducted with 18 fathers of children with LLI. Six fathers had experienced the death of their child. The overarching themes were stresses, means of coping, and perceived needs for support. Generally, fathers in this study struggled relative to discursive and internalized notions of fathers as providers and protectors for their children, combined with an inability to ease their child's vulnerability to LLI. Participants were engaged in the care of their child with LLI, but several felt marginalized by health care providers in care planning and staff/family communication. Some fathers recognized and valued their support network while others had few supports. Some described personal growth and desired to help other fathers. Practice implications and recommendations include renewed application of family-centered care, overcoming presumptions about fathers' roles, and recognizing the impact of LLI beyond physical health.
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Affiliation(s)
- David B Nicholas
- a Faculty of Social Work, Central and Northern Alberta Region , University of Calgary , Edmonton , Alberta , Canada
| | - Laura Beaune
- b Department of Social Work , The Hospital for Sick Children , Toronto , Ontario , Canada
| | - Maru Barrera
- c Department of Psychology , The Hospital for Sick Children , Toronto , Ontario , Canada
- d Institute of Medical Sciences, DLSPH and OISE , University of Toronto , Toronto , Ontario , Canada
| | - Jonathan Blumberg
- e The Hospital for Sick Children Family Advisory Network , Toronto , Ontario , Canada
| | - Mark Belletrutti
- f Stollery Children's Hospital , Edmonton , Alberta , Canada
- g Department of Pediatrics , University of Alberta , Edmonton , Alberta , Canada
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Siminoff LA, Molisani AJ, Traino HM. A Comparison of the Request Process and Outcomes in Adult and Pediatric Organ Donation. Pediatrics 2015; 136:e108-14. [PMID: 26034251 PMCID: PMC4485007 DOI: 10.1542/peds.2014-3652] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although existing studies suggest that factors affecting families' decisions regarding pediatric organ donation mirror those for adult patients, health professionals working in this area maintain that pediatric and adult decision-makers differ in significant ways. This study compared the request process, experiences, and authorization decisions between family decision-makers (FDMs) of adult and pediatric donors and nondonors. METHODS Perceptions of the donation request were collected via telephone interviews with 1601 FDMs approached by staff from 9 US organ procurement organizations (OPOs). Authorization regarding donation (ie, authorized/refused) was obtained from FDM reports and verified by using OPO records. Tests of association were used to estimate differences between FDMs of adult and pediatric patients. A logistic regression analysis was conducted to identify variables predicting FDM authorization. RESULTS FDMs of children were significantly more likely to authorize donation than were FDMs of adults (89.7% vs 83.2%; χ(2) = 6.2, P = .01). Differences were found between pediatric and adult families' initial feelings toward donation, donation-related topics discussed, communication behaviors and techniques used, perceptions of the request, and receipt and preference of grief information. The likelihood of FDM authorization increased with the number of topics discussed and communication skills employed during requests. Authorization was not predicted by patient age (ie, adult versus pediatric). CONCLUSIONS FDMs of children are willing to donate and experience no more psychological distress from the request for donation than do FDMs of adults. Communication emerged as a critical factor of family authorization, reinforcing its importance in requests for donation.
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Affiliation(s)
- Laura A. Siminoff
- Department of Public Health, Temple University, Philadelphia, Pennsylvania; and
| | - Anthony J. Molisani
- Department of Social and Behavioral Health, Virginia Commonwealth University, Richmond, Virginia
| | - Heather M. Traino
- Department of Public Health, Temple University, Philadelphia, Pennsylvania; and
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Lotz JD, Jox RJ, Borasio GD, Führer M. Pediatric advance care planning from the perspective of health care professionals: a qualitative interview study. Palliat Med 2015; 29:212-22. [PMID: 25389347 PMCID: PMC4359209 DOI: 10.1177/0269216314552091] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pediatric advance care planning differs from the adult setting in several aspects, including patients' diagnoses, minor age, and questionable capacity to consent. So far, research has largely neglected the professionals' perspective. AIM We aimed to investigate the attitudes and needs of health care professionals with regard to pediatric advance care planning. DESIGN This is a qualitative interview study with experts in pediatric end-of-life care. A qualitative content analysis was performed. SETTING/PARTICIPANTS We conducted 17 semi-structured interviews with health care professionals caring for severely ill children/adolescents, from different professions, care settings, and institutions. RESULTS Perceived problems with pediatric advance care planning relate to professionals' discomfort and uncertainty regarding end-of-life decisions and advance directives. Conflicts may arise between physicians and non-medical care providers because both avoid taking responsibility for treatment limitations according to a minor's advance directive. Nevertheless, pediatric advance care planning is perceived as helpful by providing an action plan for everyone and ensuring that patient/parent wishes are respected. Important requirements for pediatric advance care planning were identified as follows: repeated discussions and shared decision-making with the family, a qualified facilitator who ensures continuity throughout the whole process, multi-professional conferences, as well as professional education on advance care planning. CONCLUSION Despite a perceived need for pediatric advance care planning, several barriers to its implementation were identified. The results remain to be verified in a larger cohort of health care professionals. Future research should focus on developing and testing strategies for overcoming the existing barriers.
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Affiliation(s)
- Julia D Lotz
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University, Munich, Germany
| | - Gian Domenico Borasio
- Service de Soins Palliatifs, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Monika Führer
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
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45
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de Vos MA, Bos AP, Plötz FB, van Heerde M, de Graaff BM, Tates K, Truog RD, Willems DL. Talking with parents about end-of-life decisions for their children. Pediatrics 2015; 135:e465-76. [PMID: 25560442 DOI: 10.1542/peds.2014-1903] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Retrospective studies show that most parents prefer to share in decisions to forgo life-sustaining treatment (LST) from their children. We do not yet know how physicians and parents communicate about these decisions and to what extent parents share in the decision-making process. METHODS We conducted a prospective exploratory study in 2 Dutch University Medical Centers. RESULTS Overall, 27 physicians participated, along with 37 parents of 19 children for whom a decision to withhold or withdraw LST was being considered. Forty-seven conversations were audio recorded, ranging from 1 to 8 meetings per patient. By means of a coding instrument we quantitatively and qualitatively analyzed physicians' and parents' communicative behaviors. On average, physicians spoke 67% of the time, parents 30%, and nurses 3%. All physicians focused primarily on providing medical information, explaining their preferred course of action, and informing parents about the decision being reached by the team. Only in 2 cases were parents asked to share in the decision-making. Despite their intense emotions, most parents made great effort to actively participate in the conversation. They did this by asking for clarifications, offering their preferences, and reacting to the decision being proposed (mostly by expressing their assent). In the few cases where parents strongly preferred LST to be continued, the physicians either gave parents more time or revised the decision. CONCLUSIONS We conclude that parents are able to handle a more active role than they are currently being given. Parents' greatest concern is that their child might suffer.
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Affiliation(s)
- Mirjam A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands;
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Frans B Plötz
- Department of Paediatrics, Tergooiziekenhuizen, Hilversum, Netherlands
| | - Marc van Heerde
- Department of Paediatric Intensive Care, VU University Medical Centre, Amsterdam, Netherlands
| | - Bert M de Graaff
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Kiek Tates
- Department of Communication and Information Studies, Tilburg University, Tilburg, Netherlands; and
| | - Robert D Truog
- Division of Critical Care Medicine, Boston Children's Hospital; Division of Medical Ethics, Harvard Medical School, Boston, Massachusetts
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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de Vos MA, Seeber AA, Gevers SKM, Bos AP, Gevers F, Willems DL. Parents who wish no further treatment for their child. JOURNAL OF MEDICAL ETHICS 2015; 41:195-200. [PMID: 24917616 DOI: 10.1136/medethics-2013-101395] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In the ethical and clinical literature, cases of parents who want treatment for their child to be withdrawn against the views of the medical team have not received much attention. Yet resolution of such conflicts demands much effort of both the medical team and parents. OBJECTIVE To discuss who can best protect a child's interests, which often becomes a central issue, putting considerable pressure on mutual trust and partnership. METHODS We describe the case of a 3-year-old boy with acquired brain damage due to autoimmune-mediated encephalitis whose parents wanted to stop treatment. By comparing this case with relevant literature, we systematically explored the pros and cons of sharing end-of-life decisions with parents in cases where treatment is considered futile by parents and not (yet) by physicians. CONCLUSIONS Sharing end-of-life decisions with parents is a more important duty for physicians than protecting parents from guilt or doubt. Moreover, a request from parents on behalf of their child to discontinue treatment is, and should be, hard to over-rule in cases with significant prognostic uncertainty and/or in cases with divergent opinions within the medical team.
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Affiliation(s)
- Mirjam A de Vos
- Section of Medical Ethics, Division of Public Health and Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Antje A Seeber
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjef K M Gevers
- Department of Health Law, Division of Public Health & Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital/Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Dick L Willems
- Section of Medical Ethics, Division of Public Health and Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Heckford E, Beringer AJ. Advance Care Planning: Challenges and Approaches for Pediatricians. J Palliat Med 2014; 17:1049-53. [PMID: 24955940 DOI: 10.1089/jpm.2013.0374] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Emma Heckford
- Community Children's Health Partnership, North Bristol Trust, Southmead Hospital, Bristol, United Kingdom
| | - Antonia Jane Beringer
- Faculty of Health and Life Sciences, University of the West of England, Bristol, United Kingdom
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Fox D, Brittan M, Stille C. The Pediatric Inpatient Family Care Conference: a proposed structure toward shared decision-making. Hosp Pediatr 2014; 4:305-310. [PMID: 25318113 DOI: 10.1542/hpeds.2014-0017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Over the past decade, there has been a steady increase in the medical complexity of patients on the pediatric inpatient service while at the same time, there are few data to show that families are satisfied with communication of complex issues. Family care conferences are defined as an opportunity outside of rounds to meet and discuss treatment decisions and options. They offer a potential pathway for psychosocial support and facilitated communication. The lack of consensus about the structure of these conferences impedes our ability to research patient, family, and provider outcomes related to communication. The goal of the present article was to describe a structure for family care conferences in the pediatric inpatient setting with a literature-based description of each phase of the conference. The theoretical framework for the structure is that patient and family engagement can improve communication and ultimately health care quality. This proposed model offers guidance to providers and researchers whose goal is to improve communication on the inpatient service.
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Affiliation(s)
- David Fox
- Department of Pediatrics, University of Colorado, Aurora, Colorado; and Children's Outcomes Research, Children's Hospital Colorado, Aurora, Colorado
| | - Mark Brittan
- Department of Pediatrics, University of Colorado, Aurora, Colorado; and Children's Outcomes Research, Children's Hospital Colorado, Aurora, Colorado
| | - Chris Stille
- Department of Pediatrics, University of Colorado, Aurora, Colorado; and Children's Outcomes Research, Children's Hospital Colorado, Aurora, Colorado
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Pascual-Fernández MC. [Providing information to patient's families on the end of life process in the intensive care unit. Nursing evaluation]. ENFERMERIA CLINICA 2014; 24:168-74. [PMID: 24530045 DOI: 10.1016/j.enfcli.2013.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 09/04/2013] [Accepted: 09/07/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Informing is a process that includes many aspects and when it involves a family member at the end of life it becomes a complicated matter, not only for giving the information, but also for the mood of family members. Thus, the information should be adapted to the language and education of the patient and family. That information must be proper and suitable to the moment. OBJECTIVE To describe the aspects of information offered to relatives of patients in the end of life process in Intensive Care Units (ICU), and to determine the nursing evaluation in this process. To evaluate the professionals' attitude on this subject. MATERIAL AND METHOD An observational study conducted on nurses in pediatric and adult ICU nurses of a large public health hospital complexes in the city of Madrid. The data was collected using a questionnaire on the evaluation of care of children who died in pediatric ICU. RESULTS The majority of the nurses, 71% (159), said that the information was given in a place alone with the doctor. More than half (52.4%, 118) considered that the information was sufficient/insufficient depending on the day. Significant differences were found as regards the behavior of the staff at the time of a death in (P<.01), with pediatric ICU professionals being more empathetic. CONCLUSIONS ICU nurses believe that the information is appropriate for the prognosis and adapted to the patient situation. They also consider the place where the information is given and the attitude of the professionals in the end of life process are adequate.
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Affiliation(s)
- M Cristina Pascual-Fernández
- Supervisora de Urgencia Infantil, Hospital General Universitario Gregorio Marañón, Diplomado Universitario de Enfermería, Máster de Enfermería en Cuidados Críticos, Universidad Rey Juan Carlos, Doctora por la Universidad Rey Juan Carlos, Madrid, España.
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50
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Affiliation(s)
- Beverley Copnell
- Beverley Copnell is a senior lecturer at the School of Nursing and Midwifery, Monash University, in Melbourne, Australia
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