The role of hospice in the transition from hospital to home for technology-dependent children-A qualitative study

Arrangement of residence before hospital discharge for children on home-invasive mechanical ventilation

Children on long-term home mechanical ventilation are a growing population due to clinical and technological advances and the benefit for the child's quality of life. Invasive home ventilation is one of the most complex therapies offered in the home setting, requiring adequate home environment and appropriate equipment and supplies before discharge. The transition from hospital to home represents a vulnerable period that can be facilitated with an established transition plan with multidisciplinary team involvement. Readiness for home care is achieved when the patient is stable and has been transitioned from a critical care ventilator to a home mechanical ventilator. In parallel, comprehensive competency-based training regarding the knowledge and skills needed to help families use the equipment confidently and safely. Before discharge, families should be counseled on an adequate home environment to ensure a safe transition. The residence arrangement may include physical space modifications, verifying electrical installation, or moving to another home. Durable medical equipment and supplies must be ordered, and community healthcare support arranged. Parents should receive practical advice on setting up the equipment at home and on preventive measures to minimize complications related to tracheostomy and ventilator dependence, including regular maintenance and replacement of necessary equipment. Given the overall impact of invasive ventilation on home life, a structured home care action package is essential to alleviate the burdens involved.

Places of Farewell: A Scoping Review Exploring Factors Influencing the Choice of Place of Death for Children when Death is Expected

Progression of ill health and death trajectories is different for children with a non-oncology diagnosis. As previous research has focused primarily on children with cancer diagnoses, this scoping review explored what factors influence the parent and/or child's choice of place of death for a child with a non-oncological complex care condition, when death is expected. Eighteen papers were identified considering the preferred place of death. The findings were themed into 1. Diagnostic Factors; 2. Home Factors; 3. Socio-economic Factors; 4. Parent Factors. In conclusion, informed discussions with families that recognize the reason for, and the impact of their choices, are necessary not only for the preferred place of death but also end of life care.

A qualitative meta-synthesis of patient dignity from the perspective of caregivers

BACKGROUND

The concept of dignity remains disputed, with most studies defining dignity based on its external dimension. Although its inherent dimension is a rooted attribute of dignity, it has received scarce attention. Caregivers have close relationships with their care recipients and thus may perceive their patient's inherent as well as external dimensions of dignity. Therefore, in this study, we aimed to identify, analyze, and synthesize evidence on human dignity presented in qualitative studies from the perspective of caregivers to gain a deeper comprehension of the preservation of patients' dignity by their caregivers.

METHODS

A qualitative meta-synthesis was performed by searching for relevant qualitative literature via systematic electronic databases, including MEDLINE, PsycINFO, ProQuest, CINAHL, Embase, Health Source, and Web of Science, from inception to March 15, 2022.

RESULTS

Nine studies were eligible for inclusion and included in the meta-synthesis. Three overarching categories were identified: integrated person, "rootedness" and "growth" atmosphere, and balanced state.

CONCLUSIONS

Dignity is rooted in its inherent dimension, whereas its external dimension may promote individual dignity. Furthermore, caregiver-patient relationships may be a key factor linking the inherent dimension of dignity with its external dimension. Thus, further studies should focus on the mechanism of relationships in preserving dignity.

Transition from intensive care unit to a portable ventilator in children with severe bronchopulmonary dysplasia

As the population of ventilator-dependent children (VDC) with tracheostomies due to underlying severe bronchopulmonary dysplasia grows, there is an increasing need to shift the care of these children from hospital to home. Transitioning the ventilator-dependent child from the hospital to home is a complex process that requires coordination between the medical team and the family. One crucial step in the process is transitioning from an Intensive care unit (ICU) ventilator to a portable home ventilator (PHV). The Clinical team needs to understand the nuances in transitioning to PHV, including assessing readiness to transition and choosing the optimum settings on an available home ventilator. In recent years, various ventilator modes have been available in PHV that can help achieve synchronous breathing to allow for adequate gas exchange for the infant. This review details some approaches to asses readiness to transition and the process of Transition along with commonly used modes of support available in PHV, as well as the primary and secondary settings in which we should be mindful in supporting a child with chronic respiratory failure in the home setting.

Traumatic Childbirth Experiences of New Parents: A Meta-Synthesis

Childbirth is usually a joyous occasion. However, a significant proportion of parents experienced traumatic childbirths and suffered post-traumatic consequences, which needs urgent attention. Therefore, this review aimed to explore and understand the traumatic childbirth experiences of parents. A systematic review of qualitative studies was done. The consolidated evidence was meta-summarized and meta-synthesized based on Sandelowski and Barroso's approach for synthesizing qualitative research. Seven electronic databases, including PubMed, CINAHL, Embase, PsycINFO, Cochrane, Scopus, and Web of Science, were searched from each database's inception to April 2020. Retrieved studies were screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and 19 studies were included in this review. All included studies were meta-summarized and meta-synthesized. An overarching theme, "traumatic birth: an evolving voyage," with three main themes, (1) "proceedings to traumatic birth," (2) "internal and external battles," and (3) "muddling through to beating the odds," and 10 subthemes were identified. Overall, parents felt fluctuations of emotions that seemed to be never-ending journeys. They expressed that various factors led to their traumatic birth experiences, especially health care providers' dismissive attitudes. Parents commonly reported feelings of powerlessness and fear for the safety of mothers and infants. Their constant battles to overcome traumatic experiences affected some of their relationships. To deal with the trauma, some mothers displayed avoidance behaviors while others relied on social support. As health care providers play important roles in influencing outcomes of childbirth, they should be mindful of the care provided during labors and childbirths.

Palliative Care in Paediatric Oncology: an Update

Purpose of this Review

The purpose of this review is to describe the evolution of palliative care in paediatric oncology, the needs of children and their families in a paediatric oncology setting, palliative care referral practices in paediatric oncology, outcomes of palliative care referral in paediatric oncology and models of palliative care in paediatric oncology.

Recent Findings

Cancer constitutes 5.2% of the palliative care needs in children. Approximately, 90% of children with cancer lives in low and middle-income countries, constituting 84% of the global burden of childhood cancers. Children in low and middle-income countries have low cure rates and high death rates making palliative care relevant in a paediatric oncology setting. Children with cancer experience pain and physical symptoms, low mood, anxiety, and fear. They feel less resilient, experience low self-worth, and have challenges coping with the illness. The families lead very stressful lives, navigating the hospital environment, and dealing with uncertainties of the future. Palliative care referral in children with cancer improves physical symptoms, emotional support, and quality of life. It enables communication between families and health care providers. It improves end-of-life care support to children and their families and facilitates less invasive diagnostic and therapeutic interventions at the end of life. Worldwide children with cancer are infrequently referred to palliative care and referred late in the illness trajectory. Most of the children referred to palliative care receive some form of cancer-directed therapy in their last days. Children in low and low-middle income countries are less likely to access palliative care due to a lack of awareness amongst paediatric oncologists about palliative care and the reduced number of services providing palliative care. A three-tier model is proposed to provide palliative care in paediatric oncology, where most children with palliative care needs are managed by paediatric oncologists and a smaller number with complex physical and psychosocial needs are managed by paediatric palliative care specialists. There are several palliative care models in paediatric oncology practised globally. However, no one model was considered better or superior, and the choice of model depended on the need, preferences identified, and available resources.

Summary

Children with cancer are sparingly referred to palliative care and referred late and oncologists and haematologists gatekeep the referral process. Knowledge on palliative care referral in paediatric oncology settings might enhance collaboration between paediatric oncology and paediatric palliative care.

Experiencing place identity and place belongingness at a children's hospice: Parents' perspectives

Children's hospices are key players in the provision of palliative care services for families with children with life-limiting conditions (LLCs). However, evidence suggests that some of the negative terminology/language which surrounds the notions of palliative and hospice care may contribute to the lack of uptake of hospice services by families. This article reports two elements of place bonding: parents' experiences of place identity and place belongingness at a children's hospice in a region in England. Underpinned by a constructivist grounded theory methodology, focus groups were undertaken with 24 parents of children with LLCs accessing a children's hospice. Despite initial reservations associated with the identity of the hospice, parents described how and why their view changed and therefore consequently how they were able to experience the hospice differently. This article demonstrates how parents' views of the identity of the hospice change and how the hospice becomes a place where parents experience a sense of belongingness.

Developing a nursing dependency scoring tool for children's palliative care: the impact on hospice care

BACKGROUND

Occupancy is commonly used to measure bed management in hospices. However, the increasing complexity of children and young people and growing dependence on technology mean that this is no longer effective.

AIM

To develop a dependency tool that enables the hospice to safely and effectively manage the use of beds for planned short breaks (respite care), preserving capacity for children requiring symptom management and end-of-life care.

METHODS

A comprehensive literature review and existing tools were used to inform the development of the Martin House Dependency Tool Framework. Training was provided to staff and the tool was piloted before applying it across the hospice caseload.

FINDINGS

The tool has been used on 431 children (93.1% of caseload). The tool enabled consistency of assessment and more effective management of resources, due to a contemporaneous understanding of the clinical needs of those on the caseload.

CONCLUSION

The tool has enabled consistent and transparent assessment of children, improving safety, effectiveness and responsiveness, and the management of the workforce and resources.

Parents' experiences of transition from hospital to home of a child with complex health needs: A systematic literature review

AIMS AND OBJECTIVES

To critically appraise primary research on the views and experiences of parents of children with complex health needs during the transition from hospital to home.

BACKGROUND

Children with complex health needs frequently transition across and within healthcare systems, due to their age, care needs and ongoing health conditions. Repeated and unplanned admissions are significantly higher for children with complex health needs. Yet parents, as the primary providers of care, report being unsupported and unprepared during the transition from hospital back to home due to poor communication, inadequate discharge planning and education, resulting in stress and anxiety within the home environment.

DESIGN

Systematic review following PRISMA guidelines.

METHODS

A systematic search was completed of the databases CINAHL, MEDLINE, PsycINFO, EMBASE and the Cochrane Library Review between January 2009 and September 2019. Data were extracted, categorised and analysed using a thematic analysis approach. An adapted CASP qualitative assessment tool was utilised for quality assessment. All included articles were marked for validity and relevance to current research with an overall score from 0-20.

RESULTS

A total of 13 studies of mixed quality were identified. CASP quality scores ranged from 13-18. Four themes emerged highlighting parents' experiences of the emotional processes, communication, coordination and support and resources when transitioning from hospital to home.

CONCLUSIONS

Hospital discharge and transition from hospital to home is a complicated and at times frustrating process for parents of children with complex health needs. Parents report being exhausted and stressed during this often-challenging period of adjustment which was perceived as a difficult and emotional process. There is a clear lack of support available for parents both from hospital and community services.

Parents' perceptions of the transition of their child who is ventilator dependent from hospital to home

The number of children who are ventilator dependent and being cared for at home by their families has risen dramatically in recent years. Parents' roles are often taken for granted, with little recognition of the effect of the shift from parent to carer on families. The aim of this literature review was to explore parents' perceptions of the burden of care placed on them during the transition of their child who depends on a ventilator from hospital to home, the support they received during discharge and any gaps in continuity of care. An electronic database search was undertaken of PubMed, Cumulative Index to Nursing and Allied Health Literature and PsycINFO. After exclusion a total of 14 studies were reviewed and critiqued. The main themes identified were: transition: preparing for discharge; feelings of isolation on transitioning home; and the strive for normality or a sense of control felt by parents and family members. Where facilitated, families are more than capable of providing skilled, competent care at home to a child who is ventilator dependent. The long-term effects of this arrangement are largely unknown so far, but the literature shows that it has a substantial psychosocial effect on families. More information and education for healthcare professionals is required about the experiences of these families to appreciate the struggles they face after discharge. This may have a positive effect on how nurses and other professionals support parents during the discharge process.

Changes in Care- A Systematic Scoping Review of Transitions for Children with Medical Complexities

BACKGROUND

Children with medical complexity (CMC) and their parents are affected physically and mentally during transitions in care. Coordinated models of care show promise in improving health outcomes.

OBJECTIVE

The purpose of this scoping review was to examine research related to CMC and their parents and transitions in care. The aim was 3-fold: (1) to examine the extent, range, and nature of research activity related to the impact of transitions on physical and mental health for CMC and their parents; (2) to summarize and disseminate research findings for key knowledge users; and (3) to identify research gaps in the existing literature to inform future studies.

METHODS

Twenty-three sources were identified through database searches and five articles met the inclusion criteria of CMC (multi-organ involvement or technology-dependent) (or parents of CMC) transitioning from hospital to alternate levels of care where outcome measures were physical or mental health-related.

RESULTS

Numerical analysis revealed substantial variation in methodological approaches and outcome measures. Content analysis revealed two themes for parents of CMC during this transition: (1) emotional distress, and (2) high expectations; and three themes for CMC: (1) improved health, (2) changes in emotion, and (3) disrupted relationships.

CONCLUSION

The findings from this scoping review reveal for parents, transitions in care are fraught with emotional distress and high expectations; and for CMC there are improvements in quality of life and emotional health post- hospital to home transitions when collaborative models of care are available. This review serves as an early attempt to summarize the literature and demonstrate a need for further research.

The Prevalence of Nonprescription Cannabinoid-Based Medicines in British Children's Hospices: Results of a National Survey

Background: Almost 50,000 children and young people are affected by life-limiting conditions in the United Kingdom, around a third of which use children's hospices. Anecdotal evidence suggests that cannabinoid-based medicines (CBMs), specifically cannabis oil (CO), are being used by families with increasing frequency to manage distressing symptoms. The use of most nonprescription CBMs in the United Kingdom remains illegal. Objective: The objective of the study was to identify the prevalence of CO use by families who use children's hospices in the United Kingdom, and the approaches taken by those services to manage it. Design: An electronic survey was sent to each of the 54 children's hospices in the United Kingdom between May and July 2018, comprising 10 questions. Results: Forty children's hospices from across the four countries of the United Kingdom responded to the survey, representing 74% of British children's hospices. About 87.5% of hospices knew of children who use CO therapeutically. Sixty-nine percent of those hospices have received requests to administer CO during an episode of care. Approaches by organizations around CO management varied across the sectors, including arrangements for storage, administration, and recording of its use. Hospices highlighted how the lack of available guidance made decision making more challenging. Only a third of responding organizations routinely questioned families about the use of cannabis when prescribing medicines. Conclusion: CO is used extensively by children who use children's hospices. Despite recognizing the use of CO, many hospices are unable to support it. There is a need for clear guidelines on how hospices should approach the care needs of children, allowing hospices to meet the needs of children who use CO, and families in a safe, consistent, and relevant way, safeguarding all children, families, and professionals within the organization.

Compassionate Discharges From the PICU

OBJECTIVES

This article focuses on compassionate discharge from an ICU setting for pediatric patients.

DATA SOURCES

Not Applicable.

STUDY SELECTION

Not Applicable.

DATA EXTRACTION

Not Applicable.

DATA SYNTHESIS

The rationale for compassionate discharge is described, along with suggestions for assessing feasibility. A patient case highlights the potential benefits of and provides specific examples of steps involved in the process. A general framework for consideration of compassionate discharge, along with a checklist, is provided to highlight the importance of detailed planning and communication.

CONCLUSIONS

Although many children die in an ICU setting, some families desire end-of-life care in a nonhospital setting, often at home. For children dependent on technology, there are considerable logistical challenges to overcome, and it may not always be possible. However, with meticulous planning and close collaboration between intensive care staff, palliative care staff, and other community services, compassionate discharge can be done successfully and provide the child and family the opportunity for end-of-life care in the place most meaningful to them.