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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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Iten R, O'Connor M, Gill FJ. Palliative care for infants with life-limiting conditions: integrative review. BMJ Support Palliat Care 2023:spcare-2023-004435. [PMID: 38123923 DOI: 10.1136/spcare-2023-004435] [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: 06/15/2023] [Accepted: 11/22/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Infants with life-limiting conditions are a heterogeneous population. Palliative care for infants is delivered in a diverse range of healthcare settings and by interdisciplinary primary healthcare teams, which may not involve specialist palliative care service consultation. OBJECTIVE To synthesise the literature for how palliative care is delivered for infants aged less than 12 months with life-limiting conditions. METHODS An integrative review design. MEDLINE, CINAHL, ProQuest, Cochrane, Joanna Briggs Institute and EMBASE were searched for research published in English language, from 2010 to 2022, and peer reviewed. Critical appraisal was completed for 26 patient case series, 9 qualitative, 5 cross-sectional and 1 quality improvement study. Data analysis involved deductive content analysis and narrative approach to summarise the synthesised results. RESULTS 37 articles met the eligibility for inclusion. Two models of palliative care delivery were examined, demonstrating differences in care received and experiences of families and health professionals. Health professionals reported lack of palliative care education, challenges for delivering palliative care in intensive care settings and barriers to advance care planning including prognostic uncertainty and transitioning to end-of-life care. Families reported positive experiences with specialist palliative care services and challenges engaging in advance care planning discussions. CONCLUSION There are complex issues surrounding the provision of palliative care for infants. Optimal palliative care should encompass a collaborative and coordinated approach between the primary healthcare teams and specialist palliative care services and prioritisation of palliative care education for nurses and physicians involved in providing palliative care to infants.
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Affiliation(s)
- Rebecca Iten
- Curtin University, Perth, Western Australia, Australia
- Perth Children's Hospital, Nedlands, Western Australia, Australia
| | | | - Fenella J Gill
- Curtin University, Perth, Western Australia, Australia
- Perth Children's Hospital, Nedlands, Western Australia, Australia
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Iten R, O'Connor M, Cuddeford L, Gill FJ. Care management trajectories of infants with life-limiting conditions who died before 12 months of age; a retrospective patient health record review. J Pediatr Nurs 2022; 70:e22-e31. [PMID: 36463014 DOI: 10.1016/j.pedn.2022.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 10/11/2022] [Accepted: 11/11/2022] [Indexed: 12/02/2022]
Abstract
PURPOSE To characterise the care management trajectories of infants with life-limiting conditions, who died before 12 months, including clinical decision-making processes, identification of triggers that led to changes in care management from cure-orientated to palliative care and specialist palliative care team involvement. DESIGN AND METHODS Retrospective patient health record review of infants with life-limiting conditions who died before 12 months of age and received care at three hospitals in Western Australia. Two data analysis methods; directed content analysis and process mapping. RESULTS A total of 45 patient health records were reviewed. Process mapping led to typology of care management encompassing four trajectories; early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until a significant point; and early treatment limits. Standardised advance care planning processes were used for just over 10% of infants. There was specialist palliative care team involvement for 25% of infants. CONCLUSION Only a proportion of infants received early integration of palliative care principles and practices. Infants and their families may benefit from earlier integration of palliative care, and standardised processes for advance care planning that are done in parallel to treatment. PRACTICE IMPLICATIONS There is opportunity to further enhance the delivery of palliative care to infants with life-limiting conditions and optimise the experience for families through education for health professionals, implementation of advance care planning and standardisation through policies and clinical practice guidelines.
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Affiliation(s)
- Rebecca Iten
- School of Nursing, Faculty Health Sciences, Curtin University, Perth 6102, WA, Australia; Perth Children's Hospital, Child and Adolescent Health Service, 15 Hospital Avenue, Nedlands 6009, WA, Australia.
| | - Moira O'Connor
- School of Population Health, Faculty Health Science, Curtin University, Perth 6102, WA, Australia.
| | - Lisa Cuddeford
- Perth Children's Hospital, Child and Adolescent Health Service, 15 Hospital Avenue, Nedlands 6009, WA, Australia.
| | - Fenella J Gill
- School of Nursing, Faculty Health Sciences, Curtin University, Perth 6102, WA, Australia; Perth Children's Hospital, Child and Adolescent Health Service, 15 Hospital Avenue, Nedlands 6009, WA, Australia; Enable Institute, Curtin University, Perth 6102, WA, Australia.
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Zhong Y, Cavolo A, Labarque V, Gastmans C. Physician decision-making process about withholding/withdrawing life-sustaining treatments in paediatric patients: a systematic review of qualitative evidence. BMC Palliat Care 2022; 21:113. [PMID: 35751075 PMCID: PMC9229823 DOI: 10.1186/s12904-022-01003-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background With paediatric patients, deciding whether to withhold/withdraw life-sustaining treatments (LST) at the end of life is difficult and ethically sensitive. Little is understood about how and why physicians decide on withholding/withdrawing LST at the end of life in paediatric patients. In this study, we aimed to synthesise results from the literature on physicians’ perceptions about decision-making when dealing with withholding/withdrawing life-sustaining treatments in paediatric patients. Methods We conducted a systematic review of empirical qualitative studies. Five electronic databases (Pubmed, Cinahl®, Embase®, Scopus®, Web of Science™) were exhaustively searched in order to identify articles published in English from inception through March 17, 2021. Analysis and synthesis were guided by the Qualitative Analysis Guide of Leuven. Results Thirty publications met our criteria and were included for analysis. Overall, we found that physicians agreed to involve parents, and to a lesser extent, children in the decision-making process about withholding/withdrawing LST. Our analysis to identify conceptual schemes revealed that physicians divided their decision-making into three stages: (1) early preparation via advance care planning, (2) information giving and receiving, and (3) arriving at the final decision. Physicians considered advocating for the best interests of the child and of the parents as their major focus. We also identified moderating factors of decision-making, such as facilitators and barriers, specifically those related to physicians and parents that influenced physicians’ decision-making. Conclusions By focusing on stakeholders, structure of the decision-making process, ethical values, and influencing factors, our analysis showed that physicians generally agreed to share the decision-making with parents and the child, especially for adolescents. Further research is required to better understand how to minimise the negative impact of barriers on the decision-making process (e.g., difficult involvement of children, lack of paediatric palliative care expertise, conflict with parents). Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01003-5.
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Affiliation(s)
- Yajing Zhong
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium.
| | - Alice Cavolo
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium
| | - Veerle Labarque
- Centre for Molecular and Vascular Biology, Faculty of Medicine, KU Leuven/UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium
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Carr K, Hasson F, McIlfatrick S, Downing J. Initiation of paediatric advance care planning: Cross-sectional survey of health professionals reported behaviour. Child Care Health Dev 2022; 48:423-434. [PMID: 34873744 PMCID: PMC9306788 DOI: 10.1111/cch.12943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Globally, initiation of paediatric advance care planning discussions is advocated early in the illness trajectory; however, evidence suggests it occurs at crisis points or close to end of life. Few studies have been undertaken to ascertain the prevalence and determinants of behaviour related to initiation by the healthcare professional. METHOD Underpinned by the Capability, Opportunity, Motivation-Behaviour (COM-B) model for behaviour change, a cross-sectional online survey was conducted in United Kingdom and Ireland using a purposive sample of health professionals. Descriptive and inferential statistics were applied and nonparametric statistical analysis used. Open-ended questions were mapped and correlations between COM-B and demographic profiles identified. RESULTS Responses (n = 140): Paediatric advance care planning was viewed positively; however, initiation practices were found to be influenced by wide ranging diagnoses and disease trajectories. Whilst some tools and protocols exist, they were not used in a systematic manner, and initiation behaviour was often not guided by them. Initiation was unstandardized, individually led, guided by intuition and experience and based on a range of prerequisites. Such behaviour, combined with inconsistencies in professional development, resulted in varying practice when managing clinical deterioration. Professionals who felt adequately trained initiated more conversations (capability). Those working in palliative care specialties, hospice settings and doctors initiated more discussions (opportunity). There was no difference in Motivation between professions, clinical settings or specialisms, although 25% (n = 35) of responses indicated discomfort discussing death and 34% (n = 49) worried about families' emotional reaction. CONCLUSION Although advocated, paediatric advance care planning is a complex process, commonly triggered by the physical deterioration and rarely underpinned by support tools. The COM-B framework was useful in identifying fundamental differences in initiation behaviour; however, further research is required to explore the complexity of initiation behaviour and the system within which the care is being delivered to identify influences on initiation.
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Affiliation(s)
- Karen Carr
- Institute of Nursing and Health ResearchUlster UniversityNewtownabbeyUK
| | - Felicity Hasson
- Institute of Nursing and Health ResearchUlster UniversityNewtownabbeyUK
| | - Sonja McIlfatrick
- Institute of Nursing and Health ResearchUlster UniversityNewtownabbeyUK
| | - Julia Downing
- International Children's Palliative Care NetworkBristolUK,Department of MedicineMakerere UniversityKampalaUganda
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