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Liesse KM, Malladi L, Dinh TC, Wesp BM, Kam BN, Turturice BA, Pyke-Grimm KA, Char DS, Hollander SA. Trajectories in Intensity of Medical Interventions at the End of Life: Clustering Analysis in a Pediatric, Single-Center Retrospective Cohort, 2013-2021. Pediatr Crit Care Med 2024:00130478-990000000-00365. [PMID: 39023327 DOI: 10.1097/pcc.0000000000003579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
OBJECTIVE Pediatric deaths often occur within hospitals and involve balancing aggressive treatment with minimization of suffering. This study first investigated associations between clinical/demographic features and the level of intensity of various therapies these patients undergo at the end of life (EOL). Second, the work used these data to develop a new, broader spectrum for classifying pediatric EOL trajectories. DESIGN Retrospective, single-center study, 2013-2021. SETTING Four hundred sixty-one bed tertiary, stand-alone children's hospital with 112 ICU beds. PATIENTS Patients of age 0-26 years old at the time of death. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1111 included patients, 85.7% died in-hospital. Patients who died outside the hospital were older. Among the 952 in-hospital deaths, most occurred in ICUs (89.5%). Clustering analysis was used to distinguish EOL trajectories based on the presence of intensive therapies and/or an active resuscitation attempt at the EOL. We identified five simplified categories: 1) death during active resuscitation, 2) controlled withdrawal of life-sustaining technology, 3) natural progression to death despite maximal therapy, 4) discontinuation of nonsustaining therapies, and 5) withholding/noninitiation of future therapies. Patients with recent surgical procedures, a history of organ transplantation, or admission to the Cardiovascular ICU had more intense therapies at EOL than those who received palliative care consultations, had known genetic conditions, or were of older age. CONCLUSIONS In this retrospective study of pediatric EOL trajectories based on the intensity of technology and/or resuscitation discontinued at the EOL, we have identified associations between these trajectories and patient characteristics. Further research is needed to investigate the impact of these trajectories on families, patients, and healthcare providers.
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Affiliation(s)
- Kelly M Liesse
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Lakshmee Malladi
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Tu C Dinh
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Brendan M Wesp
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Brittni N Kam
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | | | - Kimberly A Pyke-Grimm
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Danton S Char
- Division of Pediatric Anesthesia, Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
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Ting J, Songer K, Bailey V, Rotman C, Lipsitz S, Rosenberg AR, Delgado-Corcoran C, Moynihan KM. Impact of Subspecialty Pediatric Palliative Care on Children with Heart Disease; A Systematic Review and Meta-analysis. Pediatr Cardiol 2024:10.1007/s00246-024-03535-4. [PMID: 38907871 DOI: 10.1007/s00246-024-03535-4] [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: 03/16/2024] [Accepted: 05/23/2024] [Indexed: 06/24/2024]
Abstract
While many experts in pediatric cardiology have emphasized the importance of palliative care involvement, very few studies have assessed the influence of specialty pediatric palliative care (SPPC) involvement for children with heart disease. We conducted a systematic review using keywords related to palliative care, quality of life and care-satisfaction, and heart disease. We searched PubMed, EMBASE, CINAHL, CENTRAL and Web of Science in December 2023. Screening, data extraction and methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Pairs of trained reviewers independently evaluated each article. All full texts excluded from the review were hand-screened for eligible references including systematic reviews in general pediatric populations. Two reviewers independently extracted: (1) study design; (2) methodology; (2) setting; (3) population; (4) intervention/exposure and control definition; (5) outcome measures; and (6) results. Of 4059 studies screened, 9 met inclusion criteria including two with overlapping patient data. Study designs were heterogenous, including only one randomized control and two historical control trials with SPPC as a prospective intervention. Overall, there was moderate to high risk of bias. Seven were single centers studies. In combined estimates, patients who received SPPC were more likely to have advance care planning documented (RR 2.7, [95%CI 1.6, 4.7], p < 0.001) and resuscitation limits (RR 4.0, [2.0, 8.1], p < 0.001), while half as likely to have active resuscitation at end-of-life ([0.3, 0.9], p = 0.032). For parental stress, receipt of SPPC improved scores by almost half a standard deviation (RR 0.48, 95%CI 0.10, 0.86) more than controls. Ultimately, we identified a paucity of high-quality data studying the influence of SPPC; however, findings correlate with literature in other pediatric populations. Findings suggest benefits of SPPC integration for patients with heart disease and their families.
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Affiliation(s)
- James Ting
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Kathryn Songer
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Valerie Bailey
- Department of Cardiology, Boston Children's Hospital, MS BCH3215, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Chloe Rotman
- Medical Library, Boston Children's Hospital, Boston, MA, USA
| | - Stuart Lipsitz
- Department of General Internal Medicine and Primary Care, Center for Patient Safety, Research, and Practice, Brigham and Women's Hospital, Boston, MA, USA
| | - Abby R Rosenberg
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | | | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, MS BCH3215, 300 Longwood Ave, Boston, MA, 02115, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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García-Fernández J, Romero-García M, Benito-Aracil L, Pilar Delgado-Hito M. Humanisation in paediatric intensive care units: A narrative review. Intensive Crit Care Nurs 2024:103725. [PMID: 38824005 DOI: 10.1016/j.iccn.2024.103725] [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: 11/28/2023] [Revised: 05/02/2024] [Accepted: 05/17/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE To identify findings in the scientific literature relevant to the strategic lines proposed by the Humanising Intensive Care Project in the context of paediatric intensive care units. DESIGN Narrative review. METHODS A literature search was conducted in the databases PubMed, Scopus, CINHAL, and Cochrane Library. Specific indexing terms and search strategies adapted to each database were designed. The inclusion of publications was based on two criteria: 1) related to the paediatric intensive care unit and 2) addresses at least one of the topics related to the strategic lines of the Humanising Intensive Care Project. Study selection was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the quality of the included studies was assessed using the Mixed Method Appraisal tool. RESULTS A total of 100 articles from 19 different countries were included, covering the period between 2019 and 2021. Nineteen different design types were identified. Thirty-two studies were cross-sectional observational studies, while 15 had an experimental approach. The articles were distributed among the seven strategic lines of the Humanising Intensive Care Project. CONCLUSIONS Synthesising the knowledge related to humanisation in paediatric intensive care units will allow progress to be made in improving quality in these units. However, there is disparity in the amount of experimental research overall. IMPLICATIONS FOR CLINICAL PRACTICE There is a disparity in the available research related to the different strategic lines, and it is necessary to carry out more exhaustive research on topics such as the presence and participation of the family in care or the management of post-paediatric intensive care syndrome.
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Affiliation(s)
- Javier García-Fernández
- Multidisciplinary Nursing Research Group of the Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Marta Romero-García
- Fundamental and Clinical Nursing Department, Faculty of Nursing, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; GRIN-IDIBELL, Institute of Biomedical Research, L'Hospitalet de Llobregat, Barcelona, Spain; International Research Project for the Humanisation of Health Care, HU-CI Project: Humanising Intensive Care (HU-CI) Project, Collado Villalba, Madrid, Spain.
| | - Llúcia Benito-Aracil
- Fundamental and Clinical Nursing Department, Faculty of Nursing, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; GRIN-IDIBELL, Institute of Biomedical Research, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Mª Pilar Delgado-Hito
- Fundamental and Clinical Nursing Department, Faculty of Nursing, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; GRIN-IDIBELL, Institute of Biomedical Research, L'Hospitalet de Llobregat, Barcelona, Spain; International Research Project for the Humanisation of Health Care, HU-CI Project: Humanising Intensive Care (HU-CI) Project, Collado Villalba, Madrid, Spain
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4
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Broden EG, Bailey VK, Beke DM, Snaman JM, Moynihan KM. Dying and Death in a Pediatric Cardiac ICU: Mixed Methods Evaluation of Multidisciplinary Staff Responses. Pediatr Crit Care Med 2024; 25:e91-e102. [PMID: 37678228 DOI: 10.1097/pcc.0000000000003357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Understanding factors influencing quality of pediatric end-of-life (EOL) care is necessary to identify interventions to improve family and staff experiences. We characterized pediatric cardiac ICU (PCICU) staff free-text survey responses to contextualize patterns in quality of dying and death (QODD) scoring. DESIGN This mixed methods study reports on a cross-sectional survey of PCICU staff involved in patient deaths. SETTING Single, quaternary PCICU from 2019-2021. PARTICIPANTS Multidisciplinary staff (bedside nurses, allied health professionals, and medical practitioners) rated QODD and voluntarily added free-text responses. We derived descriptive categories of free-text responses using content analysis. Response sentiment was classified as positive, negative or both positive and negative. We compared category and sentiment frequency by discipline, EOL medical intensity, years of experience and QODD score quartiles. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 60 deaths and 713 completed staff surveys, 269 (38%) contained free-text responses, including 103 of 269 (38%) from nurses. Of six qualitative categories (i.e., relational dynamics, clinical circumstances, family experiences, emotional expressions, temporal conditions, and structural/situational factors), relational dynamics was most frequent (173 responses). When compared by discipline, family experiences were more common in nursing responses than medical practitioners or allied health. High intensity was associated with infrequent discussion of family experience and greater focus on temporal conditions and clinical circumstances. Emotional expressions and temporal conditions were more common in lowest QODD quartile surveys. Although 45% staff responses contained both sentiments, relational dynamics and family experiences were more likely positive. Negative sentiments were more common in the lowest QODD quartile surveys and responses containing temporal conditions or structural/situational factors. CONCLUSIONS Synergistic relationships between the multidisciplinary team and family shaped clinician's positive responses. Attention to team dynamics may be a crucial ingredient in interventions to improve EOL care. Our data support that team-based education initiatives should consider differential foci between disciplines and EOL characteristics.
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Affiliation(s)
- Elizabeth G Broden
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Valerie K Bailey
- Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Boston, MA
| | - Dorothy M Beke
- Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Boston, MA
| | - Jennifer M Snaman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Katie M Moynihan
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Sadler K, Khan S, AlGhamdi K, Alyami HH, Nancarrow L. Addressing 10 Myths About Pediatric Palliative Care. Am J Hosp Palliat Care 2024; 41:193-202. [PMID: 37144635 DOI: 10.1177/10499091231174202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
With advances in biomedical sciences, a growing number of conditions affecting children have evolved from being considered life-limiting to almost chronic diseases. However, improvements in survival rates often come at a cost of increased medical complexity and lengthy hospitalizations, which can be associated with a poorer quality of life. This is where pediatric palliative care (PPC) can play a significant role. PPC is a specialty of healthcare that focuses on the prevention and relief of suffering in children with serious conditions. Unfortunately, despite the well-identified need for PPC services across pediatric specialties, multiple misconceptions persist. Common myths about palliative care are identified and deconstructed in light of the most recent evidenced-based references in the field to provide guidance to healthcare providers to address these. PPC is often associated with end-of-life care, loss of hope, and cancer. Some healthcare providers and parents also believe that information like diagnosis should be withheld from children for their emotional protection. These examples of misconceptions hinder the integration of pediatric palliative care and its additional layer of support and clinical expertise. PPC providers have advanced communication skills, are able to instill hope in the face of uncertainty, are trained to initiate and implement individualized pain and symptom management plans, and understand how to improve the quality of life in children with serious illnesses. Improved awareness about the scope of PPC is needed to ensure that children benefit from the maximum expertise and support throughout their complex health trajectories.
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Affiliation(s)
- Kim Sadler
- Oncology and Liver Diseases Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saadiya Khan
- Pediatric Hematology-Oncology Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Khaled AlGhamdi
- General Pediatrics Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hamad Hussain Alyami
- Pediatric Hematology-Oncology Nursing Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Lori Nancarrow
- Children's Palliative Care Department, Whittington Health NHS Trust, London, UK
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6
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Walker M, Nicolardi D, Christopoulos T, Ross T. Hospital, hospice, or home: A scoping review of the importance of place in pediatric palliative care. Palliat Support Care 2023; 21:925-934. [PMID: 37357946 DOI: 10.1017/s1478951523000664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
BACKGROUND Palliative care necessitates questions about the preferred place for delivering care and location of death. Place is integral to palliative care, as it can impact proximity to family, available resources/support, and patient comfort. Despite the importance of place, there is remarkably little literature exploring its role in pediatric palliative care (PPC). OBJECTIVES To understand the importance and meaning of place in PPC. METHODS We conducted a scoping review to understand the importance of place in PPC. Five databases were searched using keywords related to "pediatric," "palliative," and "place." Two reviewers screened results, extracted data, and analyzed emergent themes pertaining to place. RESULTS From 3076 search results, we identified and reviewed 25 articles. The literature highlights hospital, home, and hospice as 3 distinct PPC places. Children and their families have place preferences for PPC and place of death, and a growing number prefer death to occur at home. Results also indicate numerous factors influence place preferences (e.g., comfort, grief, cultural/spiritual practices, and socioeconomic status). SIGNIFICANCE OF RESULTS Place influences families' PPC decisions and experiences and thus warrants further study. Greater understanding of the importance and roles of place in PPC could enhance PPC policy and practice, as well as PPC environments.
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Affiliation(s)
- Meaghan Walker
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
| | - Danielle Nicolardi
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
| | - Téa Christopoulos
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
| | - Timothy Ross
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
- Department of Geography & Planning, University of Toronto, Toronto, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
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Delgado-Corcoran C, Wawrzynski SE, Flaherty B, Kirkland B, Bodily S, Moore D, Cook LJ, Olson LM. Extracorporeal membrane oxygenation and paediatric palliative care in an ICU. Cardiol Young 2023; 33:1846-1852. [PMID: 36278475 DOI: 10.1017/s1047951122003018] [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] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Compare rates, clinical characteristics, and outcomes of paediatric palliative care consultation in children supported on extracorporeal membrane oxygenation admitted to a single-centre 16-bed cardiac or a 28-bed paediatric ICU. METHODS Retrospective review of clinical characteristics and outcomes of children (aged 0-21 years) supported on extracorporeal membrane oxygenation between January, 2017 and December, 2019 compared by palliative care consultation. MEASUREMENTS AND RESULTS One hundred children (N = 100) were supported with extracorporeal membrane oxygenation; 19% received a palliative care consult. Compared to non-consulted children, consulted children had higher disease severity measured by higher complex chronic conditions at the end of extracorporeal membrane oxygenation hospitalisation (5 versus. 3; p < 0.001), longer hospital length of stay (92 days versus 19 days; p < 0.001), and higher use of life-sustaining therapies after decannulation (79% versus 23%; p < 0.001). Consultations occurred mainly for longitudinal psychosocial-spiritual support after patient survived device deployment with a median of 27 days after cannulation. Most children died in the ICU after withdrawal of life-sustaining therapies regardless of consultation status. Over two-thirds of the 44 deaths (84%; n = 37) occurred during extracorporeal membrane oxygenation hospitalisation. CONCLUSIONS Palliative care consultation was rare showing that palliative care consultation was not viewed as an acute need and only considered when the clinical course became protracted. As a result, there are missed opportunities to involve palliative care earlier and more frequently in the care of extracorporeal membrane survivors and non-survivors and their families.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
- University of Utah, College of Nursing, 10 S 2000 E, Salt Lake City, UT, USA
| | - Brian Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
| | - Brandon Kirkland
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
| | - Stephanie Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Dominic Moore
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
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Chen SH, Wu ET, Wang CC, Su MY, Chang CH, Chen HL, Lu FL, Cheng SY. Increasing Trend and Effects of Pediatric Palliative Care on Children With Noncancer Diagnoses. J Pain Symptom Manage 2023; 66:230-237.e1. [PMID: 37290731 DOI: 10.1016/j.jpainsymman.2023.05.018] [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: 02/16/2023] [Revised: 05/18/2023] [Accepted: 05/30/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Pediatric palliative care (PPC), especially among noncancer pediatric patients, faces challenges including late referral, limited patient care, and insufficient data for Asian patients. METHODS This retrospective cohort study used the integrative hospital medical database between 2014 and 2018 to analyze the clinical characteristics, diagnoses, and end-of-life care for patients aged less than 20 who had died in our children's hospital, a tertiary referral medical center implementing PPC shared-care. RESULTS In our cohort of 323 children, 240 (74.3%) were noncancer patients who a younger median age at death (5 vs. 122 months, P < 0.001), lower rate of PPC involvement (16.7 vs. 66%, P < 0.001), and fewer survival days after PPC consult compared to cancer patients (3 vs. 11, P = 0.01). Patients not receiving PPC had more ventilator support (OR 9.9, P < 0.001), and less morphine use on their final day of life (OR 0.1, P < 0.001). Also, patients not receiving PPC had more cardiopulmonary resuscitation on the last day of life (OR 15.3, P < 0.001) and died in the ICU (OR 8.8, P < 0.001). There was an increasing trend of noncancer patients receiving PPC between 2014 and 2018 (P < 0.001). CONCLUSIONS High disparities exist between children receiving PPC in cancer versus noncancer patients. The concept of PPC is gradually becoming accepted in noncancer children and is associated with more pain-relief medication and less suffering during end-of-life care.
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Affiliation(s)
- Szu-Han Chen
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - En-Ting Wu
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Chia Wang
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Min-Yu Su
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Division of Pediatric Hematology and Oncology (M.Y.S.), China Medical University Children's Hospital, Taichung, Taiwan
| | - Chin-Hao Chang
- Department of Medical Research (C.H.C.), National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Ling Chen
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department and Graduate Institute of Medical Education and Bioethics (H.L.C.), National Taiwan University College of Medicine, Taipei, Taiwan
| | - Frank Leigh Lu
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Shao-Yi Cheng
- Department of Family Medicine (S.Y.C.), National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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9
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Bernier Carney KM, Goodrich G, Lao A, Tan Z, Kiza AH, Cong X, Hinderer KA. Palliative care referral criteria and application in pediatric illness care: A scoping review. Palliat Med 2023; 37:692-706. [PMID: 36971413 DOI: 10.1177/02692163231163258] [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] [Indexed: 05/30/2023]
Abstract
BACKGROUND Specialty pediatric palliative care services can help to address unmet care needs for children with complex and serious illness. Current guidelines support the identification of unmet palliative care needs; however, it is unknown how these guidelines or other clinical characteristics influence pediatric palliative care referral in research and practice. AIM To evaluate the identification and application of palliative care referral criteria in pediatric illness care and research. DESIGN A scoping review with a content analysis approach to summarize results. DATA SOURCES Five electronic databases (PubMed, CINAHL, PsycINFO, SCOPUS, and Academic Search Premier) were used to identify peer-reviewed literature published in English between January 2010 and September 2021. RESULTS We included 37 articles focused on the referral of pediatric patients to palliative care teams. The identified categories of referral criteria were: disease-related; symptom-related; treatment communication; psychosocial, emotional, and spiritual support; acute care needs; end-of-life care needs; care management needs; and self-referrals for pediatric palliative care services. We identified two validated instruments to facilitate palliative care referral and seven articles which described population-specific interventions to improve palliative care access. Nineteen articles implemented a retrospective health record review approach that consistently identified palliative care needs with varying rates of service use. CONCLUSIONS The literature demonstrates inconsistent methods for identifying and referring children and adolescents with unmet palliative care needs. Prospective cohort studies and clinical trials would inform more consistent pediatric palliative care referral practices. More research is needed on palliative care referral and outcomes in community-focused pediatrics.
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Affiliation(s)
| | - George Goodrich
- School of Nursing, University of Connecticut, Storrs, CT, USA
| | - Amberly Lao
- Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Zewen Tan
- School of Medicine, University of Connecticut, Farmington, CT, USA
| | | | - Xiaomei Cong
- School of Nursing, University of Connecticut, Storrs, CT, USA
- School of Nursing, Yale University, Orange, CT, USA
| | - Katherine A Hinderer
- School of Nursing, University of Connecticut, Storrs, CT, USA
- School of Medicine, University of Connecticut, Farmington, CT, USA
- Institute for Nursing Research and Evidence-Based Practice, Connecticut Children's, Hartford, CT, USA
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10
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Edwards JD. A Focused Review of Long-Stay Patients and the Ethical Imperative to Provide Inpatient Continuity. Semin Pediatr Neurol 2023; 45:101037. [PMID: 37003634 DOI: 10.1016/j.spen.2023.101037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 02/17/2023] [Accepted: 02/19/2023] [Indexed: 04/03/2023]
Abstract
Long-stay patients are an impactful, vulnerable, growing group of inpatients in today's (and tomorrow's) tertiary hospitals. They can outlast dozens of clinicians that necessarily rotate on and off clinical service. Yet, care from such rotating clinicians can result in fragmented care due to a lack of continuity that insufficiently meets the needs of these patients and their families. Using long-stay PICU patients as an example, this focused review discusses the impact of prolonged admissions and how our fragmented care can compound this impact. It also argues that it is an ethical imperative to provide a level of continuity of care beyond what is considered standard of care and offers a number of strategies that can provide such continuity.
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Affiliation(s)
- Jeffrey D Edwards
- Section of Critical Care, Department of Pediatrics, Columbia University Vagelos College of Physician and Surgeons, New York, NY..
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Hollander SA, Pyke-Grimm KA, Shezad MF, Zafar F, Cousino MK, Feudtner C, Char DS. End-of-Life in Pediatric Patients Supported by Ventricular Assist Devices: A Network Database Cohort Study. Pediatr Crit Care Med 2023; 24:41-50. [PMID: 36398973 DOI: 10.1097/pcc.0000000000003115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Most pediatric patients on ventricular assist device (VAD) survive to transplantation. Approximately 15% will die on VAD support, and the circumstances at the end-of-life are not well understood. We, therefore, sought to characterize patient location and invasive interventions used at the time of death. DESIGN Retrospective database study of a cohort meeting inclusion criteria. SETTING Thirty-six centers participating in the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Registry. PATIENTS Children who died on VAD therapy in the period March 2012 to September 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 117 of 721 patients (16%) who died on VAD, the median (interquartile range) age was 5 years (1-16 yr) at 43 days (17-91 d) postimplant. Initial goals of therapy were bridge to consideration for candidacy for transplantation in 60 of 117 (51%), bridge to transplantation in 44 of 117 (38%), bridge to recovery 11 of 117 (9%), or destination therapy (i.e., VAD as the endpoint) in two of 117 (2%). The most common cause of death was multiple organ failure in 35 of 117 (30%), followed by infection in 12 of 117 (10%). Eighty-five of 92 (92%) died with a functioning device in place. Most patients were receiving invasive interventions (mechanical ventilation, vasoactive infusions, etc.) at the end of life. Twelve patients (10%) died at home. CONCLUSIONS One-in-six pediatric VAD patients die while receiving device support, with death occurring soon after implant and usually from noncardiac causes. Aggressive interventions are common at the end-of-life. The ACTION Registry data should inform future practices to promote informed patient/family and clinician decision-making to hopefully reduce suffering at the end-of-life.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA
| | - Kimberly A Pyke-Grimm
- Departments of Pediatrics (Hematology/Oncology), and Nursing Research and Evidence-Based Practice, Stanford University, Palo Alto, CA
| | - Muhammad F Shezad
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Melissa K Cousino
- Departments of Pediatrics and Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Chris Feudtner
- Department of Pediatrics (General Pediatrics), Children's Hospital of Philadelphia, Philadelphia, PA
| | - Danton S Char
- Department of Anesthesia (Pediatric Cardiac), Stanford University, Palo Alto, CA
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12
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Bailey V, Beke DM, Snaman JM, Alizadeh F, Goldberg S, Smith-Parrish M, Gauvreau K, Blume ED, Moynihan KM. Assessment of an Instrument to Measure Interdisciplinary Staff Perceptions of Quality of Dying and Death in a Pediatric Cardiac Intensive Care Unit. JAMA Netw Open 2022; 5:e2210762. [PMID: 35522280 PMCID: PMC9077481 DOI: 10.1001/jamanetworkopen.2022.10762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Lack of pediatric end-of-life care quality indicators and challenges ascertaining family perspectives make staff perceptions valuable. Cardiac intensive care unit (CICU) interdisciplinary staff play an integral role supporting children and families at end of life. OBJECTIVES To evaluate the Pediatric Intensive Care Unit Quality of Dying and Death (PICU-QODD) instrument and examine differences between disciplines and end-of-life circumstances. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional survey included staff at a single center involved in pediatric CICU deaths from July 1, 2019, to June 30, 2021. EXPOSURES Staff demographic characteristics, intensity of end-of-life care (mechanical support, open chest, or cardiopulmonary resuscitation [CPR]), mode of death (discontinuation of life-sustaining therapy, treatment limitation, comfort care, CPR, and brain death), and palliative care involvement. MAIN OUTCOMES AND MEASURES PICU-QODD instrument standardized score (maximum, 100, with higher scores indicating higher quality); global rating of quality of the moment of death and 7 days prior (Likert 11-point scale, with 0 indicating terrible and 10, ideal) and mode-of-death alignment with family wishes. RESULTS Of 60 patient deaths (31 [52%] female; median [IQR] age, 4.9 months [10 days to 7.5 years]), 33 (55%) received intense care. Of 713 surveys (72% response rate), 246 (35%) were from nurses, 208 (29%) from medical practitioners, and 259 (36%) from allied health professionals. Clinical experience varied (298 [42%] ≤5 years). Median (IQR) PICU-QODD score was 93 (84-97); and quality of the moment of death and 7 days prior scores were 9 (7-10) and 5 (2-7), respectively. Cronbach α ranged from 0.87 (medical staff) to 0.92 (allied health), and PICU-QODD scores significantly correlated with global rating and alignment questions. Mean (SD) PICU-QODD scores were more than 3 points lower for nursing and allied health compared with medical practitioners (nursing staff: 88.3 [10.6]; allied health: 88.9 [9.6]; medical practitioner: 91.9 [7.8]; P < .001) and for less experienced staff (eg, <2 y: 87.7 [8.9]; >15 y: 91, P = .002). Mean PICU-QODD scores were lower for patients with comorbidities, surgical admissions, death following treatment limitation, or death misaligned with family wishes. No difference was observed with palliative care involvement. High-intensity care, compared with low-intensity care, was associated with lower median (IQR) rating of the quality of the 7 days prior to death (4 [2-6] vs 6 [4-8]; P = .001) and of the moment of death (8 [4-10] vs 9 [8-10]; P =.001). CONCLUSIONS AND RELEVANCE In this cross-sectional survey study of CICU staff, the PICU-QODD showed promise as a reliable and valid clinician measure of quality of dying and death in the CICU. Overall QODD was positively perceived, with lower rated quality of 7 days prior to death and variation by staff and patient characteristics. Our data could guide strategies to meaningfully improve CICU staff well-being and end-of-life experiences for patients and families.
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Affiliation(s)
- Valerie Bailey
- Cardiovascular and Critical Care Nursing Patient Services, Boston Children’s Hospital, Boston, Massachusetts
| | - Dorothy M. Beke
- Cardiovascular and Critical Care Nursing Patient Services, Boston Children’s Hospital, Boston, Massachusetts
| | - Jennifer M. Snaman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Faraz Alizadeh
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sarah Goldberg
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth D. Blume
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Katie M. Moynihan
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Sydney Medical School, University of Sydney, Sydney, Australia
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13
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Moynihan KM, Ziniel SI, Johnston E, Morell E, Pituch K, Blume ED. A "Good Death" for Children with Cardiac Disease. Pediatr Cardiol 2022; 43:744-755. [PMID: 34854941 DOI: 10.1007/s00246-021-02781-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/17/2021] [Indexed: 11/25/2022]
Abstract
Children with heart disease often experience symptoms and medically intense end-of-life care. Our study explored bereaved parents' perceptions of a "good death" via a mail survey to 128 parents of children with heart disease who died in two centers. Parental perceptions of end-of-life circumstances were assessed by closed-ended questions including level of agreement with the question: "would you say your child experienced a good death?" and open-ended comments were contributed. Medical therapies at end-of-life and mode of death were retrieved through chart review. Of 50 responding parents, 44 (response rate: 34%) responded to the "good death" question; 16 (36%) agreed strongly, 15 (34%) agreed somewhat, and 30% disagreed (somewhat: 7, 16%; strongly: 6, 14%). Half the children were on mechanical support and 84% intubated at death. Of children with cardiopulmonary resuscitation (CPR) at end-of-life, 71% of parents disagreed with the "good death" question compared with 22% of parents whose child died following discontinuation of life-sustaining therapy or comfort measures (OR 9.1, 95% CI 1.3, 48.9, p < 0.01). Parent-reported circumstances associated with disagreement with the "good death" question included cure-oriented goals-of-care (OR 16.6, 95% CI 3.0, 87.8, p < 0.001), lack of advance care planning (ACP) (OR 12.4 95% CI 2.1, 65.3 p < 0.002), surprise regarding timing of death (OR 11.7, 95% CI 2.6, 53.4 p < 0.002), and experience of pain (OR 42.1, 95% CI 2.3, 773.7 p < 0.02). Despite high medical intensity, many bereaved parents of children with cardiac disease agree a "good death" was experienced. A "good death" was associated with greater preparedness, ACP, non-cure-oriented goals-of-care, pain control, and CPR avoidance.
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Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, MS BCH3215, 300 Longwood Avenue, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sonja I Ziniel
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Emily Johnston
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Emily Morell
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Kenneth Pituch
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, MS BCH3215, 300 Longwood Avenue, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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14
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Delgado-Corcoran C, Wawrzynski SE, Mansfield KJ, Flaherty B, DeCourcey DD, Moore D, Cook LJ, Ullrich CK, Olson LM. An Automatic Pediatric Palliative Care Consultation for Children Supported on Extracorporeal Membrane Oxygenation: A Survey of Perceived Benefits and Barriers. J Palliat Med 2022; 25:952-957. [PMID: 35319287 DOI: 10.1089/jpm.2021.0452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Pediatric palliative care (PPC) consultation is infrequent among children on extracorporeal membrane oxygenation (ECMO). Objective: Investigate intensive care unit (ICU) team members' perceptions of automatic PPC consultation for children on ECMO in an ICU in the United States. Methods: Cross-sectional survey assessing benefits, barriers to PPC, and consultation processes. Results: Of 291 eligible respondents, 48% (n = 140) completed the survey and 16% (n = 47) answered an open-ended question. Benefits included support in decision-making (n = 98; 70%) and identification of goals of care (n = 89; 64%). Barriers included perception of giving up on families (n = 59; 42%) and poor acceptability by other team members (n = 58; 41%). Respondents endorsed communication with the primary ICU team before (n = 122; 87%) and after (n = 129; 92%) consultation. Open-ended responses showed more positive (79% vs. 13%) than negative statements. Positive statements reflected on expanding PPC to other critically-ill children where negative statements revealed unrecognized value in PPC. Conclusions: Results demonstrate opportunities for education about the scope of PPC and improvements in PPC delivery.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.,Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah, USA.,College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | | | - Brian Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Christina K Ullrich
- Division of Pediatric Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Lenora M Olson
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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Abstract
OBJECTIVES Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs. DATA SOURCES English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed. STUDY SELECTION Original articles, review articles, and commentaries were considered. DATA EXTRACTION Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review. DATA SYNTHESIS Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured. CONCLUSIONS The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.
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16
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Palliative Care Utilization Following Out-of-Hospital Cardiac Arrest in Pediatrics. Crit Care Explor 2022; 10:e0639. [PMID: 35211682 PMCID: PMC8860333 DOI: 10.1097/cce.0000000000000639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES: Pediatric out-of-hospital cardiac arrest (OHCA) is associated with significant morbidity and mortality. Pediatric palliative care (PPC) services could provide an integral component of the comprehensive care necessary for these patients and their families. The main objectives of this study are to examine the utilization of PPC following OHCA and compare the differences in characteristics between children who received PPC with those who did not. DESIGN: Retrospective cohort study. SETTING: An urban, tertiary PICU. PATIENTS: Children less than 21 years old admitted from October 2009 to October 2019 with an admitting diagnosis of OHCA and minimum PICU length of stay (LOS) of 48 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 283 patient charts reviewed, 118 patient encounters met inclusion criteria. Of those, 34 patients (28.8%) received a PPC consultation during hospitalization. Patients who received PPC had a longer PICU LOS (14.5 vs 4.0 d), a greater number of ventilator days (12.5 vs 4.0 d), and a larger proportion of do-not-resuscitate (DNR) statuses (41% vs 19%). When comparing the disposition of survivors, a greater proportion was discharged to rehab or nursing facilities (47% vs 28%), with no difference in mortality rates (53% vs 50%). In the multivariate logistic regression model, older age, longer LOS, and code status (DNR) were all associated with higher likelihood of PPC utilization. Data were analyzed using descriptive, Mann-Whitney U, and Fisher exact statistics. CONCLUSIONS: Our study demonstrates PPC services following OHCA are underutilized given the high degree of morbidity and mortality. The impact of automatic PPC consultation in all OHCA patients who survive beyond 48 hours should be explored further. Future studies are warranted to understand the benefits and barriers of PPC integration into standard postarrest care for patients and families.
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17
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Moynihan KM, Lelkes E, Kumar RK, DeCourcey DD. Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care. Eur J Pediatr 2022; 181:479-487. [PMID: 34599379 DOI: 10.1007/s00431-021-04277-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.
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Affiliation(s)
- Katie M Moynihan
- Pediatric Intensive Care, Westmead Children's Hospital, Sydney, Australia.
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Efrat Lelkes
- Department of Pediatrics, Benioff Children's Hospital, University of California, CA, San Francisco, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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18
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Abstract
OBJECTIVE/METHODS Pediatric Palliative Care (PPC) is a multidisciplinary medical subspecialty focused on the care of children with serious illnesses and terminal diagnoses. Providers impact the care of children from the perinatal stage through adolescence/young adulthood and help patients and families face diagnoses such as complex chronic disease and malignancy. This article describes these unique populations and distinct areas of current PPC research. RESULTS Unique aspects of PPC include a high level of prognostic uncertainty, symptom burden, pediatric, and surrogate advance care planning, hope in the face of prognostic challenges, care of children at end of life, concurrent care, staff support, sibling support, and bereavement. CONCLUSION PPC's evolution from an extension of hospice into a continuum of support for families and staff caring for children with serious illnesses is exemplified in both qualitative and quantitative research. The literature proves the value that PPC can provide to families, hospitals, and communities. PPC is evolving from a supportive service into a uniquely beneficial, collaborative, educational, and interdisciplinary specialty that improves outcomes for all involved.Plain Language Summary (PLS)Pediatric Palliative Care (PPC) is a service provided to all children with serious illness as a way of addressing suffering. Populations served by PPC range from those not yet born to patients preparing for adulthood. The serious illnesses they face range from chronic disease to cancer. Over the last 20 years research has explored the unique aspects of the pediatric experience of serious illness, including prognostic uncertainty, concurrent care, symptom management, advance care planning, hope, family experience of illness, care at the end of life, staff support, and bereavement.As the number of patients who would benefit from PPC services rapidly expands nationally and worldwide, PPC teams provide education and skills training for their colleagues in primary and subspecialty fields. Hospitals benefit from PPC through improved patient experience, family-centered care, and staff support. Communities are served by PPC that occurs in and out of the hospital.Research in PPC provides guidance for challenging questions in care and has resulted in an increasingly robust body of work. PPC providers have skills of advanced communication training, hope in the face of uncertainty, targeted and personalized symptom management, and a diverse understanding of quality of life. These skills help support decision-making and establish strong connections between providers and families.The field of PPC has a distinct skillset to support families who face serious illness. This article helps medical and psychosocial providers visualize how PPC is evolving from what has often been explained to families as an added layer of support into a uniquely beneficial, collaborative, and interdisciplinary service.
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Affiliation(s)
- Benjamin Moresco
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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19
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Delgado-Corcoran C, Bennett EE, Bodily SA, Wawrzynski SE, Green D, Moore D, Cook LJ, Olson LM. Prevalence of specialised palliative care consultation for eligible children within a paediatric cardiac ICU. Cardiol Young 2021; 31:1458-1464. [PMID: 33597068 PMCID: PMC8547172 DOI: 10.1017/s1047951121000433] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Retrospectively apply criteria from Center to Advance Palliative Care to a cohort of children treated in a cardiac ICU and compare children who received a palliative care consultation to those who were eligible for but did not receive one. METHODS Medical records of children admitted to a cardiac ICU between January 2014 and June 2017 were reviewed. Selected criteria include cardiac ICU length of stay >14 days and/or ≥ 3 hospitalisations within a 6-month period. MEASUREMENTS AND RESULTS A consultation occurred in 17% (n = 48) of 288 eligible children. Children who received a consult had longer cardiac ICU (27 days versus 17 days; p < 0.001) and hospital (91 days versus 35 days; p < 0.001) lengths of stay, more complex chronic conditions at the end of first hospitalisation (3 versus1; p < 0.001) and the end of the study (4 vs.2; p < 0.001), and higher mortality (42% versus 7%; p < 0.001) when compared with the non-consulted group. Of the 142 pre-natally diagnosed children, only one received a pre-natal consult and 23 received it post-natally. Children who received a consultation (n = 48) were almost 2 months of age at the time of the consult. CONCLUSIONS Less than a quarter of eligible children received a consultation. The consultation usually occurred in the context of medical complexity, high risk of mortality, and at an older age, suggesting potential opportunities for more and earlier paediatric palliative care involvement in the cardiac ICU. Screening criteria to identify patients for a consultation may increase the use of palliative care services in the cardiac ICU.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Erin E Bennett
- Division of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital. 1 Children's Way, Little Rock, AR, 72202, USA
| | - Stephanie A Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Danielle Green
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
| | - Lenora M Olson
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
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20
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Redefining the Relationship: Palliative Care in Critical Perinatal and Neonatal Cardiac Patients. CHILDREN-BASEL 2021; 8:children8070548. [PMID: 34201973 PMCID: PMC8304963 DOI: 10.3390/children8070548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/24/2021] [Accepted: 06/08/2021] [Indexed: 12/02/2022]
Abstract
Patients with perinatal and neonatal congenital heart disease (CHD) represent a unique population with higher morbidity and mortality compared to other neonatal patient groups. Despite an overall improvement in long-term survival, they often require chronic care of complex medical illnesses after hospital discharge, placing a high burden of responsibility on their families. Emerging literature reflects high levels of depression and anxiety which plague parents, starting as early as the time of prenatal diagnosis. In the current era of the global COVID-19 pandemic, the additive nature of significant stressors for both medical providers and families can have catastrophic consequences on communication and coping. Due to the high prognostic uncertainty of CHD, data suggests that early pediatric palliative care (PC) consultation may improve shared decision-making, communication, and coping, while minimizing unnecessary medical interventions. However, barriers to pediatric PC persist largely due to the perception that PC consultation is indicative of “giving up.” This review serves to highlight the evolving landscape of perinatal and neonatal CHD and the need for earlier and longitudinal integration of pediatric PC in order to provide high-quality, interdisciplinary care to patients and families.
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21
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Green DJ, Bennett E, Olson LM, Wawrzynski S, Bodily S, Moore D, Mansfield KJ, Wilkins V, Cook L, Delgado-Corcoran C. Timing of Pediatric Palliative Care Consults in Hospitalized Patients with Heart Disease. J Pediatr Intensive Care 2021; 12:63-70. [PMID: 36742256 PMCID: PMC9894702 DOI: 10.1055/s-0041-1730916] [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: 01/27/2021] [Accepted: 04/07/2021] [Indexed: 02/07/2023] Open
Abstract
Pediatric palliative care (PPC) provides an extra layer of support for families caring for a child with complex heart disease as these patients often experience lifelong morbidities with frequent hospitalizations and risk of early mortality. PPC referral at the time of heart disease diagnosis provides early involvement in the disease trajectory, allowing PPC teams to longitudinally support patients and families with symptom management, complex medical decision-making, and advanced care planning. We analyzed 113 hospitalized pediatric patients with a primary diagnosis of heart disease and a PPC consult to identify timing of first PPC consultation in relation to diagnosis, complex chronic conditions (CCC), and death. The median age of heart disease diagnosis was 0 days with a median of two CCCs while PPC consultation did not occur until a median age of 77 days with a median of four CCCs. Median time between PPC consult and death was 33 days (interquartile range: 7-128). Death often occurred in the intensive care unit ( n = 36, 67%), and the most common mode was withdrawal of life-sustaining therapies ( n = 31, 57%). PPC referral often occurred in the context of medical complexity and prolonged hospitalization. Referral close to the time of heart disease diagnosis would allow patients and families to fully utilize PPC benefits that exist outside of end-of-life care and may influence the mode and location of death. PPC consultation should be considered at the time of heart disease diagnosis, especially in neonates and infants with CCCs.
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Affiliation(s)
- Danielle J. Green
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States,Address for correspondence Danielle J. Green, MD Department of Pediatrics, Division of Pediatric Critical CarePO Box 581289, Salt Lake City, UT 84158United States
| | - Erin Bennett
- Department of Pediatrics, Division of Critical Care, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Lenora M. Olson
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States
| | - Sarah Wawrzynski
- University of Utah College of Nursing, Salt Lake City, Utah, United States,Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, Utah, United States
| | - Stephanie Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, Utah, United States
| | - Dominic Moore
- Department of Pediatrics, Division of Palliative Care Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Kelly J. Mansfield
- Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, Utah, United States
| | - Victoria Wilkins
- Department of Pediatrics, Division of Inpatient Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Lawrence Cook
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States
| | - Claudia Delgado-Corcoran
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah, United States,Department of Pediatrics, Division of Palliative Care Medicine, University of Utah, Salt Lake City, Utah, United States
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Moynihan KM, Heith CS, Snaman JM, Smith-Parrish M, Bakas A, Ge S, Cerqueira AV, Bailey V, Beke D, Wolfe J, Morell E, Gauvreau K, Blume ED. Palliative Care Referrals in Cardiac Disease. Pediatrics 2021; 147:peds.2020-018580. [PMID: 33579811 DOI: 10.1542/peds.2020-018580] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES With evidence of benefits of pediatric palliative care (PPC) integration, we sought to characterize subspecialty PPC referral patterns and end of life (EOL) care in pediatric advanced heart disease (AHD). METHODS In this retrospective cohort study, we compared inpatient pediatric (<21 years) deaths due to AHD in 2 separate 3-year epochs: 2007-2009 (early) and 2015-2018 (late). Demographics, disease burden, medical interventions, mode of death, and hospital charges were evaluated for temporal changes and PPC influence. RESULTS Of 3409 early-epoch admissions, there were 110 deaths; the late epoch had 99 deaths in 4032 admissions. In the early epoch, 45 patients (1.3% admissions, 17% deaths) were referred for PPC, compared with 146 late-epoch patients (3.6% admissions, 58% deaths). Most deaths (186 [89%]) occurred in the cardiac ICU after discontinuation of life-sustaining therapy (138 [66%]). Medical therapies included ventilation (189 [90%]), inotropes (184 [88%]), cardiopulmonary resuscitation (68 [33%]), or mechanical circulatory support (67 [32%]), with no temporal difference observed. PPC involvement was associated with decreased mechanical circulatory support, ventilation, inotropes, or cardiopulmonary resuscitation at EOL, and children were more likely to be awake and be receiving enteral feeds. PPC involvement increased advance care planning, with lower hospital charges on day of death and 7 days before (respective differences $5058 [P = .02] and $25 634 [P = .02]). CONCLUSIONS Pediatric AHD deaths are associated with high medical intensity; however, children with PPC consultation experienced substantially less invasive interventions at EOL. Further study is warranted to explore these findings and how palliative care principles can be better integrated into care.
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Affiliation(s)
- Katie M Moynihan
- Departments of Cardiology and .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Catherine S Heith
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jennifer M Snaman
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Melissa Smith-Parrish
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Anna Bakas
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Valerie Bailey
- Cardiovascular and Critical Care Nursing Patient Services and
| | - Dorothy Beke
- Cardiovascular and Critical Care Nursing Patient Services and
| | - Joanne Wolfe
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Emily Morell
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Kimberlee Gauvreau
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elizabeth D Blume
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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