Decision making and satisfaction with care in the pediatric intensive care unit: findings from a controlled clinical trial

Prognostic and Goals-of-Care Communication in the PICU: A Systematic Review

OBJECTIVE

Admission to the PICU may result in substantial short- and long-term morbidity for survivors and their families. Engaging caregivers in discussion of prognosis is challenging for PICU clinicians. We sought to summarize the literature on prognostic, goals-of-care conversations (PGOCCs) in the PICU in order to establish current evidence-based practice, highlight knowledge gaps, and identify future directions.

DATA SOURCES

PubMed (MEDLINE and PubMed Central), EMBASE, CINAHL, PsycINFO, and Scopus.

STUDY SELECTION

We reviewed published articles (2001-2022) that examined six themes within PGOCC contextualized to the PICU: 1) caregiver perspectives, 2) clinician perspectives, 3) documentation patterns, 4) communication skills training for clinicians, 5) family conferences, and 6) prospective interventions to improve caregiver-clinician communication.

DATA EXTRACTION

Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology.

DATA SYNTHESIS

Of 1,420 publications screened, 65 met criteria for inclusion with several key themes identified. Parent and clinician perspectives highlighted the need for clear, timely, and empathetic prognostic communication. Communication skills training programs are evaluated by a participant's self-perceived improvement. Caregiver and clinician views on quality of family meetings may be discordant. Documentation of PGOCCs is inconsistent and most likely to occur shortly before death. Only two prospective interventions to improve caregiver-clinician communication in the PICU have been reported. The currently available studies reflect an overrepresentation of bereaved White, English-speaking caregivers of children with known chronic conditions.

CONCLUSIONS

Future research should identify evidence-based communication practices that enhance caregiver-clinician PGOCC in the PICU and address: 1) caregiver and clinician perspectives of underserved and limited English proficiency populations, 2) inclusion of caregivers who are not physically present at the bedside, 3) standardized communication training programs with broader multidisciplinary staff inclusion, 4) improved design of patient and caregiver educational materials, 5) the development of pediatric decision aids, and 6) inclusion of long-term post-PICU outcomes as a measure for PGOCC interventions.

A Prospective Study of Parental Perceptions of Rapid Whole-Genome and -Exome Sequencing among Seriously Ill Infants

Rapid diagnostic genomic sequencing recently became feasible for infants in intensive care units (ICUs). However, research regarding parents' perceived utility, adequacy of consent, and potential harms and benefits is lacking. Herein we report results of parental surveys of these domains from the second Newborn Sequencing in Genomic Medicine and Public Health (NSIGHT2) study, a randomized, controlled trial of rapid diagnostic genomic sequencing of infants in regional ICUs. More than 90% of parents reported feeling adequately informed to consent to diagnostic genomic sequencing. Despite only 23% (27) of 117 infants receiving genomic diagnoses, 97% (156) of 161 parents reported that testing was at least somewhat useful and 50.3% (88/161) reported no decisional regret (median 0, mean 10, range 0-100). Five of 117 families (4.3%) reported harm. Upon follow-up, one (1%) confirmed harm to child and parent related to negative results/no diagnosis, two (2%) reported stress or confusion, and two (2%) denied harm. In 81% (89) of 111 infants, families and clinicians agreed that genomic results were useful. Of the families for whom clinicians perceived harm from genomic testing, no parents reported harm. Positive tests/genomic diagnosis were more frequently perceived to be useful by parents, to benefit their infant, and to help manage potential symptoms (p < .05). In summary, the large majority of parents felt that first-tier, rapid, diagnostic genomic sequencing was beneficial for infants lacking etiologic diagnoses in ICUs. Most parents in this study perceived being adequately informed to consent, understood their child's results, and denied regret or harm from undergoing sequencing.

The impact of family centred care interventions in a neonatal or paediatric intensive care unit on parents' satisfaction and length of stay: A systematic review

OBJECTIVE

To explore the impact of family centred care interventions on parents' satisfaction and length of stay for patients admitted to a paediatric intensive care unit or a neonatal intensive care unit.

METHODS

A systematic review was conducted. Searches have been done in Cinahl, Cochrane, Embase and PubMed from February 2016 till October 2017. All included studies were quality appraised. Due to the heterogeneity of interventions findings were narratively reviewed.

RESULTS

Seventeen studies were included in this review of which 12/17 studies investigated parents' satisfaction and 7/17 length of stay. For this review two types of interventions were found. Interventions improving parents-professional collaboration which increased parents' satisfaction, and interventions improving parents' involvement which decreased length of stay. Overall quality of the included studies was weak to good.

CONCLUSIONS

Strong evidence was found for a significant decrease in length of stay when parents where participating in caring for their infant in a neonatal intensive care unit. Moderate evidence was found in parents' satisfaction, which increased when collaboration between parents and professionals at a neonatal intensive care unit improved. Studies performed in a paediatric intensive care setting were of weak to moderate quality and too few to show evidence regarding parents satisfaction and length of stay.

The Process and Impact of Stakeholder Engagement in Developing a Pediatric Intensive Care Unit Communication and Decision-Making Intervention

Stakeholder-developed interventions are needed to support pediatric intensive care unit (PICU) communication and decision-making. Few publications delineate methods and outcomes of stakeholder engagement in research. We describe the process and impact of stakeholder engagement on developing a PICU communication and decision-making support intervention. We also describe the resultant intervention. Stakeholders included parents of PICU patients, healthcare team members (HTMs), and research experts. Through a year-long iterative process, we involved 96 stakeholders in 25 meetings and 26 focus groups or interviews. Stakeholders adapted an adult navigator model by identifying core intervention elements and then determining how to operationalize those core elements in pediatrics. The stakeholder input led to PICU-specific refinements, such as supporting transitions after PICU discharge and including ancillary tools. The resultant intervention includes navigator involvement with parents and HTMs and navigator-guided use of ancillary tools. Subsequent research will test the feasibility and efficacy of our intervention.

A Narrative Synthesis of the Components of and Evidence for Patient- and Family-Centered Care

A narrative synthesis was conducted to determine typical patient- and family-centered care (PFCC) components and their link to outcomes in pediatric populations. 68 studies with PFCC interventions and experimental designs were included. Study features were synthesized based on 5 core PFCC components (i.e., education from the provider to the patient and/or family, information sharing from the family to the provider, social-emotional support, adapting care to match family background, and/or s decision-making) and 4 outcome categories (health status; the experience, knowledge, and attitudes of the patient/family; patient/family behavior; or provider behavior). The most common PFCC component was education; the least common was adapting care to family background. The presence of social-emotional support alone, as well as educational interventions augmented with shared decision-making, social-emotional support, or adaptations of care based on family background, predicted improvements in families' knowledge, attitudes, and experience. Interventions that targeted the family were associated with positive outcomes.

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

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.

Shared Decision Making in Pediatrics: A Systematic Review and Meta-analysis

BACKGROUND

Little is known about the impact of interventions to support shared decision making (SDM) with pediatric patients.

OBJECTIVES

To summarize the efficacy of SDM interventions in pediatrics on patient-centered outcomes.

DATA SOURCES

We searched Ovid Medline, Ovid Embase, Ovid Cochrane Library, Web of Science, Scopus, and Ovid PsycInfo from database inception to December 30, 2013, and performed an environmental scan.

STUDY ELIGIBILITY CRITERIA

We included interventions designed to engage pediatric patients, parents, or both in a medical decision, regardless of study design or reported outcomes.

STUDY APPRAISAL AND SYNTHESIS METHODS

We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias assessment. Meta-analysis was performed on 3 outcomes: knowledge, decisional conflict, and satisfaction.

RESULTS

Sixty-one citations describing 54 interventions met eligibility criteria. Fifteen studies reported outcomes such that they were eligible for inclusion in meta-analysis. Heterogeneity across studies was high. Meta-analysis revealed SDM interventions significantly improved knowledge (standardized mean difference [SMD] 1.21, 95% confidence interval [CI] 0.26 to 2.17, P = .01) and reduced decisional conflict (SMD -1.20, 95% CI -2.01 to -0.40, P = .003). Interventions showed a nonsignificant trend toward increased satisfaction (SMD 0.37, 95% CI -0.04 to 0.78, P = .08).

LIMITATIONS

Included studies were heterogeneous in nature, including their conceptions of SDM.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

A limited evidence base suggests that pediatric SDM interventions improve knowledge and decisional conflict, but their impact on other outcomes is unclear.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42013004761 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004761).

Evaluating the feasibility of a parent-briefing intervention in a pediatric acute care setting

PURPOSE

The purpose of this study was to test the feasibility of a parent-briefing intervention for parents of hospitalized children with complex healthcare needs.

DESIGN AND METHODS

A phase I, single-group, posttest study. There were 18 physicians, 25 nurses, and 31 parents who participated in the study. Participants were asked to sit while carrying out the briefings with parents. Parents and clinicians completed a feasibility questionnaire post briefings.

RESULTS

Sixty-eight briefings were carried out. Parents and nurses evaluated the briefings in a favorable manner, whereas physicians' ratings were mixed.

PRACTICE IMPLICATIONS

Further inquiry is recommended to understand the effects of a structured communication intervention on parent-professional decision-making practices.

Parental perspectives on suffering and quality of life at end-of-life in children with advanced heart disease: an exploratory study*

OBJECTIVE

To describe parent perspectives regarding the end-of-life experience of children with advanced heart disease.

DESIGN

Cross-sectional multicenter survey study of bereaved parents.

SETTING

Two tertiary care pediatric hospitals.

SUBJECTS

Parents of children younger than 21 years with primary cardiac diagnoses who died in the hospital 9 months to 4 years before the survey date. Parents were excluded if they were non-English speakers or had previously denied permission to contact.

INTERVENTION

The Survey for Caring for Children with Advanced Heart Disease was developed, piloted, and then sent to parents of all children who died at two sites.

MEASUREMENTS AND MAIN RESULTS

Fifty bereaved parents responded (39% response rate) a mean of 2.7 years after their child's death. Median age at death was 6 months (3.6 d to 20.4 yr). At end-of-life, 86% of children were intubated and 46% were receiving mechanical circulatory support. Seventy-eight percent died during withdrawal of life-sustaining interventions and 16% during resuscitative efforts. Parents realized that their child had no realistic chance of survival a median of 2 days prior to death (0-30 d). According to parents, 47% of children suffered "a great deal," "a lot," or "somewhat" during the end-of-life period. The symptoms parents perceived to be causing the most suffering were breathing and feeding difficulties in children under 2 years and fatigue and sleeping difficulties in older children. Seventy-one percent of parents described the quality of life of their child during the last month of life as "poor" or "fair." Most parents (84%) described the quality of care delivered as "very good" or "excellent."

CONCLUSIONS

According to their parents, many children with advanced heart disease experience suffering in the end-of-life care period. For most, realization that their child has no realistic chance of survival does not occur until late, some not until death is imminent. Once this realization occurs, however, parents perceive peacefulness, a "good death," and excellent quality of care. Strategies for improved communication around symptom management, quality of life, prognosis, and advance care planning are needed for families of children with advanced heart disease.

Bourdieu at the bedside: briefing parents in a pediatric hospital

The philosophy of family-centered care (FCC) promotes partnerships between families and staff to plan, deliver, and evaluate services for children and has been officially adopted by a majority of pediatric hospitals throughout North America. However, studies indicated that many parents have continued to be dissatisfied with their decision-making roles in their child's care. This is particularly salient for parents of children with chronic ongoing complex health problems. These children are dependent upon medical technology and require frequent hospitalizations during which parents must contribute to difficult decisions regarding their child's care. Given this clinical issue, an alternative theoretical perspective was explored to redress this problem. Pierre Bourdieu's theoretical concepts of field, capital, and habitus were used to analyze the hierarchical relationships in pediatric acute care hospitals and to design a briefing intervention aimed at improving parents' satisfaction with decision making in that health care setting.

Family-centred care for hospitalised children aged 0-12 years

BACKGROUND

This is an update of the Cochrane systematic review of family-centred care published in 2007 (Shields 2007). Family-centred care (FCC) is a widely used model in paediatrics, is thought to be the best way to provide care to children in hospital and is ubiquitous as a way of delivering care. When a child is admitted, the whole family is affected. In giving care, nurses, doctors and others must consider the impact of the child's admission on all family members. However, the effectiveness of family-centred care as a model of care has not been measured systematically.

OBJECTIVES

To assess the effects of family-centred models of care for hospitalised children aged from birth (unlike the previous version of the review, this update excludes premature neonates) to 12 years, when compared to standard models of care, on child, family and health service outcomes.

SEARCH METHODS

In the original review, we searched up until 2004. For this update, we searched: the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library, Issue 12 2011); MEDLINE (Ovid SP); EMBASE (Ovid SP); PsycINFO (Ovid SP); CINAHL (EBSCO Host); and Sociological Abstracts (CSA). We did not search three that were included in the original review: Social Work Abstracts, the Australian Medical Index and ERIC. We searched EMBASE in this update only and searched from 2004 onwards. There was no limitation by language. We performed literature searches in May and June 2009 and updated them again in December 2011.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) including cluster randomised trials in which family-centred care models are compared with standard models of care for hospitalised children (0 to 12 years, but excluding premature neonates). Studies had to meet criteria for family-centredness. In order to assess the degree of family-centredness, we used a modified rating scale based on a validated instrument, (same instrument used in the initial review), however, we decreased the family-centredness score for inclusion from 80% to 50% in this update. We also changed several other selection criteria in this update: eligible study designs are now limited to randomised controlled trials (RCTs) only; single interventions not reflecting a FCC model of care have been excluded; and the selection criterion whereby studies with inadequate or unclear blinding of outcome assessment were excluded from the review has been removed.

DATA COLLECTION AND ANALYSIS

Two review authors undertook searches, and four authors independently assessed studies against the review criteria, while two were assigned to extract data. We contacted study authors for additional information.

MAIN RESULTS

Six studies found since 2004 were originally viewed as possible inclusions, but when the family-centred score assessment was tested, only one met the minimum score of family-centredness and was included in this review. This was an unpublished RCT involving 288 children post-tonsillectomy in a care-by-parent unit (CBPU) compared with standard inpatient care.The study used a range of behavioural, economic and physical measures. It showed that children in the CBPU were significantly less likely to receive inadequate care compared with standard inpatient admission, and there were no significant differences for their behavioural outcomes or other physical outcomes. Parents were significantly more satisfied with CBPU care than standard care, assessed both before discharge and at 7 days after discharge. Costs were lower for CPBU care compared with standard inpatient care. No other outcomes were reported. The study was rated as being at low to unclear risk of bias.

AUTHORS' CONCLUSIONS

This update of a review has found limited, moderate-quality evidence that suggests some benefit of a family-centred care intervention for children's clinical care, parental satisfaction, and costs, but this is based on a small dataset and needs confirmation in larger RCTs. There is no evidence of harms. Overall, there continues to be little high-quality quantitative research available about the effects of family-centred care. Further rigorous research on the use of family-centred care as a model for care delivery to children and families in hospitals is needed. This research should implement well-developed family-centred care interventions, ideally in randomised trials. It should investigate diverse participant groups and clinical settings, and should assess a wide range of outcomes for children, parents, staff and health services.

Parental bereavement needs in the pediatric intensive care unit: review of available measures

BACKGROUND

Pediatric intensive care units (PICUs) are highly technological settings in which advanced care is used to restore health to critically ill children; however, they are also places where children die. Understanding the needs of parents bereaved in this setting is essential for better family care.

OBJECTIVE

To systematically review the extant literature to identify instruments potentially useful for assessing the needs of parents bereaved in the PICU.

METHODS

We searched PubMed™, CINAHL™, and Health and Psychosocial Instruments™ for tools to assess family needs during a relative's hospitalization. From 357 abstracts, 96 articles were reviewed that described 31 instruments. Fifteen instruments were selected based on their (1) use with parents and/or the bereaved, (2) use in PICU, neonatal intensive care, or pediatric wards, (3) measurement of family needs or related constructs, and (4) published psychometrics. Need-related constructs included satisfaction with family care and environmental stress since these have been related to met and unmet needs, respectively.

RESULTS

No instruments specifically designed to assess the needs of parents bereaved in the PICU were identified. Most tools reviewed showed validity and reliability in the populations and settings for which the tools were intended; however, validity and reliability were not established for parents bereaved in the PICU. No tools addressed the full range of needs for parents bereaved in the PICU.

CONCLUSIONS

A new instrument is needed to adequately assess the needs of parents bereaved in the PICU. Patient conditions, illness trajectories, and life course perspectives must be considered in designing a new tool.

Improving medical student intensive care unit communication skills: a novel educational initiative using standardized family members

OBJECTIVE

To determine whether intensive care unit (ICU) communication skills of fourth-year medical students could be improved by an educational intervention using a standardized family member.

DESIGN

Prospective study conducted from August 2003 to May 2004.

SETTING

Tertiary care university teaching hospital.

PARTICIPANTS

All fourth-year students were eligible to participate during their mandatory four-week critical care medicine clerkship.

INTERVENTIONS

The educational intervention focused on the initial meeting with the family member of an ICU patient and included formal teaching of a communication framework followed by a practice session with an actor playing the role of a standardized family member of a fictional patient. At the beginning of the critical care medicine rotation, the intervention group received the educational session, whereas students in the control group did not.

MEASUREMENTS AND MAIN RESULTS

At the end of each critical care medicine rotation, all students interacted with a different standardized family member portraying a different fictional scenario. Sessions were videotaped and were scored by an investigator blinded to treatment assignment using a standardized grading tool across four domains: a) introduction; b) gathering information; c) imparting information; and d) setting goals and expectations. A total of 106 (97% of eligible) medical students agreed to participate in the study. The total mean score as well as the scores for the gathering information, imparting information, setting goals, and expectations domains for the intervention group were significantly higher than for the control group (p < .01).

CONCLUSIONS

The communication skills of fourth-year medical students can be improved by teaching and then practicing a framework for an initial ICU communication episode with a standardized family member.

Parent satisfaction in pediatric intensive care: a critical appraisal of the literature

OBJECTIVE

To assess the content and characteristics of satisfaction surveys for the development of a parent satisfaction questionnaire to improve clinical practice in pediatric intensive care.

DESIGN

A structured literature review process. The databases PubMed and CINAHL were searched, via identified search terms, for relevant articles published between May 1994 and May 2004. Assessment and analysis of the material was related to development, content, reliability and validity, scales for scoring, and distribution of the satisfaction questionnaires.

MAIN RESULTS

Twelve original studies were identified using ten different satisfaction surveys in pediatric, neonatal, or adult intensive care units or in general pediatric wards. All surveys counted a total of 248 questions or statements. Six satisfaction questionnaires categorized the questions or statements in 21 different formulated domains. Most questionnaires showed sufficient results on reliability and validity. Except for one satisfaction instrument, Likert-type scales were used for rating. One study described the distribution of the questionnaire after discharge from the hospital, whereas other questionnaires were distributed during hospital admission.

CONCLUSION

The use of parent satisfaction surveys in pediatric intensive care is not well documented. Family-centered care has become widely accepted as an important issue in quality of care, and satisfaction surveys are a valuable resource for measuring and improving clinical practice. Parent satisfaction surveys need to be developed based on the needs and experiences of parents, and emphasis should be put on methodologic issues to have the results accepted as valid and effective for possible changes in clinical practice.