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Delamere T, Balfe J, Fraser LK, Sheaf G, Smith S. Defining and quantifying population-level need for children's palliative care: findings from a rapid scoping review. BMC Palliat Care 2024; 23:212. [PMID: 39174940 PMCID: PMC11340184 DOI: 10.1186/s12904-024-01539-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 07/31/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND The number of children who require palliative care has been estimated to be as high as 21 million globally. Delivering effective children's palliative care (CPC) services requires accurate population-level information on current and future CPC need, but quantifying need is hampered by challenges in defining the population in need, and by limited available data. The objective of this paper is to summarise how population-level CPC need is defined, and quantified, in the literature. METHODS Scoping review performed in line with Joanna Briggs Institute methodology for scoping reviews and PRISMA-ScR guidelines. Six online databases (CINAHL, Cochrane Library, EMBASE, Medline, PsycINFO, and Web of Science), and grey literature, were searched. INCLUSION CRITERIA literature published in English; 2008-2023 (Oct); including children aged 0-19 years; focused on defining and/or quantifying population-level need for palliative care. RESULTS Three thousand five hundred seventy-eight titles and abstracts initially reviewed, of which, 176 full-text studies were assessed for eligibility. Overall, 51 met the inclusion criteria for this scoping review. No universal agreement identified on how CPC need was defined in population-level policy and planning discussions. In practice, four key definitions of CPC need were found to be commonly applied in quantifying population-level need: (1) ACT/RCPCH (Association for Children with Life-Threatening or Terminal Conditions and their Families, and the Royal College of Paediatrics and Child Health) groups; (2) The 'Directory' of Life-Limiting Conditions; (3) 'List of Life-Limiting Conditions'; and (4) 'Complex Chronic Conditions'. In most cases, variations in data availability drove the methods used to quantify population-level CPC need and only a small proportion of articles incorporated measures of complexity of CPC need. CONCLUSION Overall, greater consistency in how CPC need is defined for policy and planning at a population-level is important, but with sufficient flexibility to allow for regional variations in epidemiology, demographics, and service availability. Improvements in routine data collection of a wide range of care complexity factors could facilitate estimation of population-level CPC need and ensure greater alignment with how need for CPC is defined at the individual-level in the clinical setting.
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Affiliation(s)
- Tara Delamere
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Joanne Balfe
- LauraLynn Ireland's Children's Hospice and Children's Health Ireland at Tallaght, Dublin, Ireland
| | - Lorna K Fraser
- Cicely Saunders Institute of Palliative Care, King's College London, London, UK
| | - Greg Sheaf
- Library of Trinity College Dublin, Dublin, Ireland
| | - Samantha Smith
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland.
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Curkovic M, Rubic F, Jozepovic A, Novak M, Filipovic-Grcic B, Mestrovic J, Lah Tomulic K, Peter B, Spoljar D, Grosek Š, Janković S, Vukovic J, Kujundžić Tiljak M, Štajduhar A, Borovecki A. Navigating the shadows: medical professionals' values and perspectives on end-of-life care within pediatric intensive care units in Croatia. Front Pediatr 2024; 12:1394071. [PMID: 39188642 PMCID: PMC11345198 DOI: 10.3389/fped.2024.1394071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 07/15/2024] [Indexed: 08/28/2024] Open
Abstract
Background and aim This study explores healthcare professionals' perspectives on end-of-life care in pediatric intensive care units (ICUs) in Croatia, aiming to illuminate their experiences with such practices, underlying attitudes, and major decision-making considerations. Amid the high variability, complexity, and emotional intensity of pediatric end-of-life decisions and practices, understanding these perspectives is crucial for improving care and policies. Methods The study utilized a cross-sectional survey intended for physicians and nurses across all pediatric ICUs in Croatia. It included healthcare professionals from six neonatal and four pediatric ICUs in total. As the data from neonatal and pediatric ICUs were examined jointly, the term pediatric ICU was used to denominate both types of ICUs. A statistical analysis was performed using Python and JASP, focusing on professional roles, professional experience, and regional differences. Results The study included a total of 103 participants (with an overall response rate-in relation to the whole target population-of 48% for physicians and 29% for nurses). The survey revealed diverse attitudes toward and experiences with various aspects of end-of-life care, with a significant portion of healthcare professionals indicating infrequent involvement in life-sustaining treatment (LST) limitation discussions and decisions, as well as somewhat ambiguous attitudes regarding such practices. Notably, discrepancies emerged between different professional roles and, in particular, regions, underscoring the high variability of LST limitation-related procedures. Conclusions The findings highlight a pressing need for more straightforward guidelines, legal frameworks, support mechanisms, and communication strategies to navigate the complex terrain of rather burdensome end-of-life pediatric care, which is intrinsically loaded with profound ethical quandaries.
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Affiliation(s)
- Marko Curkovic
- University Psychiatric Hospital Vrapče, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Filip Rubic
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ana Jozepovic
- Department of Anesthesiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Milivoj Novak
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Boris Filipovic-Grcic
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Julije Mestrovic
- Department of Pediatrics, University Hospital Centre Split, Split, Croatia
| | | | - Branimir Peter
- Department of Gynecology and Obstetrics, University Hospital Centre Rijeka, Rijeka, Croatia
| | - Diana Spoljar
- Palliative Care Service, Community Health Center Zagreb, Zagreb, Croatia
| | - Štefan Grosek
- Department of Perinatology, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Sunčana Janković
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jurica Vukovic
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Mirjana Kujundžić Tiljak
- Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Andrija Štajduhar
- Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ana Borovecki
- Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
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Davis G, Gaskin K, Molnár G, Bentley J. Places of Farewell: A Scoping Review Exploring Factors Influencing the Choice of Place of Death for Children when Death is Expected. Compr Child Adolesc Nurs 2024:1-19. [PMID: 38995682 DOI: 10.1080/24694193.2024.2374239] [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: 11/13/2023] [Accepted: 06/18/2024] [Indexed: 07/13/2024]
Abstract
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.
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Affiliation(s)
- Gilda Davis
- Three Counties School of Nursing and Midwifery, University of Worcester, Worcester, UK
| | - Kerry Gaskin
- School of Nursing and Midwifery, Birmingham City University, Birmingham, UK
| | - Gyozo Molnár
- School of Sport and Exercise Science, University of Worcester, Worcester, UK
| | - Jackie Bentley
- Three Counties School of Nursing and Midwifery, University of Worcester, Worcester, UK
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Widger K, Brennenstuhl S, Tanuseputro P, Nelson KE, Rapoport A, Seow H, Siden H, Vadeboncoeur C, Gupta S. Location of death among children with life-threatening conditions: a national population-based observational study using the Canadian Vital Statistics Database (2008-2014). CMAJ Open 2023; 11:E298-E304. [PMID: 37015742 PMCID: PMC10079309 DOI: 10.9778/cmajo.20220070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Patterns in location of death among children with life-threatening conditions (e.g., cancer, genetic disorders, neurologic conditions) may reveal important inequities in access to hospital and community support services. We aimed to identify demographic, socioeconomic and geographic factors associated with variations in location of death for children across Canada with life-threatening conditions. METHODS We used a retrospective observational cohort design and the Canadian Vital Statistics Database to identify children aged 19 years or younger who died from a life-threatening condition between Jan. 1, 2008, and Dec. 31, 2014. We used multivariable logistic regression to determine predictors of in-hospital death for children aged 1 month to 19 years, and for neonates younger than 1 month. RESULTS Overall, 13 115 decedents younger than 19 years had life-threatening conditions. Of 5250 children and 7865 neonates, 74.2% and 98.1%, respectively, died in hospital. Among children, we found a higher proportion of hospital deaths in the lowest (v. highest) income quintile (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.28-1.97), and a lower proportion among children living more than 400 km (v. < 50 km) from a pediatric hospital (OR 0.73, 95% CI 0.65-0.86). Compared with Ontario, hospital death was most common in Quebec (OR 1.38, 95% CI 1.14-1.67) and least common in British Columbia (OR 0.43, 95% CI 0.34-0.53). Compared with an oncologic cause of death, all causes except neurologic and metabolic conditions had significantly higher odds of dying in hospital. INTERPRETATION In addition to demographics, we identified socioeconomic and geographic differences in location of death, suggesting potential inequities in access to high-quality care at the end of life. Health care policies and practices must ensure equitable access to services for children across Canada, particularly at the end of their life.
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Affiliation(s)
- Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing (Widger, Brennenstuhl), University of Toronto; Hospital for Sick Children (Widger, Nelson, Rapoport, Gupta), Toronto, Ont.; Ottawa Hospital Research Institute (Tanuseputro); Department of Medicine (Tanuseputro), University of Ottawa; Bruyère Research Institute (Tanuseputro), Ottawa, Ont.; Emily's House Children's Hospice (Rapoport), Toronto, Ont.; McMaster University (Seow), Hamilton, Ont.; BC Children's Hospital (Siden); Canuck Place Children's Hospice (Siden), Vancouver, BC; Children's Hospital of Eastern Ontario (Vadeboncoeur); Roger Neilson House (Vadeboncoeur), Ottawa, Ont.
| | - Sarah Brennenstuhl
- Lawrence S. Bloomberg Faculty of Nursing (Widger, Brennenstuhl), University of Toronto; Hospital for Sick Children (Widger, Nelson, Rapoport, Gupta), Toronto, Ont.; Ottawa Hospital Research Institute (Tanuseputro); Department of Medicine (Tanuseputro), University of Ottawa; Bruyère Research Institute (Tanuseputro), Ottawa, Ont.; Emily's House Children's Hospice (Rapoport), Toronto, Ont.; McMaster University (Seow), Hamilton, Ont.; BC Children's Hospital (Siden); Canuck Place Children's Hospice (Siden), Vancouver, BC; Children's Hospital of Eastern Ontario (Vadeboncoeur); Roger Neilson House (Vadeboncoeur), Ottawa, Ont
| | - Peter Tanuseputro
- Lawrence S. Bloomberg Faculty of Nursing (Widger, Brennenstuhl), University of Toronto; Hospital for Sick Children (Widger, Nelson, Rapoport, Gupta), Toronto, Ont.; Ottawa Hospital Research Institute (Tanuseputro); Department of Medicine (Tanuseputro), University of Ottawa; Bruyère Research Institute (Tanuseputro), Ottawa, Ont.; Emily's House Children's Hospice (Rapoport), Toronto, Ont.; McMaster University (Seow), Hamilton, Ont.; BC Children's Hospital (Siden); Canuck Place Children's Hospice (Siden), Vancouver, BC; Children's Hospital of Eastern Ontario (Vadeboncoeur); Roger Neilson House (Vadeboncoeur), Ottawa, Ont
| | - Katherine E Nelson
- Lawrence S. Bloomberg Faculty of Nursing (Widger, Brennenstuhl), University of Toronto; Hospital for Sick Children (Widger, Nelson, Rapoport, Gupta), Toronto, Ont.; Ottawa Hospital Research Institute (Tanuseputro); Department of Medicine (Tanuseputro), University of Ottawa; Bruyère Research Institute (Tanuseputro), Ottawa, Ont.; Emily's House Children's Hospice (Rapoport), Toronto, Ont.; McMaster University (Seow), Hamilton, Ont.; BC Children's Hospital (Siden); Canuck Place Children's Hospice (Siden), Vancouver, BC; Children's Hospital of Eastern Ontario (Vadeboncoeur); Roger Neilson House (Vadeboncoeur), Ottawa, Ont
| | - Adam Rapoport
- Lawrence S. Bloomberg Faculty of Nursing (Widger, Brennenstuhl), University of Toronto; Hospital for Sick Children (Widger, Nelson, Rapoport, Gupta), Toronto, Ont.; Ottawa Hospital Research Institute (Tanuseputro); Department of Medicine (Tanuseputro), University of Ottawa; Bruyère Research Institute (Tanuseputro), Ottawa, Ont.; Emily's House Children's Hospice (Rapoport), Toronto, Ont.; McMaster University (Seow), Hamilton, Ont.; BC Children's Hospital (Siden); Canuck Place Children's Hospice (Siden), Vancouver, BC; Children's Hospital of Eastern Ontario (Vadeboncoeur); Roger Neilson House (Vadeboncoeur), Ottawa, Ont
| | - Hsien Seow
- Lawrence S. Bloomberg Faculty of Nursing (Widger, Brennenstuhl), University of Toronto; Hospital for Sick Children (Widger, Nelson, Rapoport, Gupta), Toronto, Ont.; Ottawa Hospital Research Institute (Tanuseputro); Department of Medicine (Tanuseputro), University of Ottawa; Bruyère Research Institute (Tanuseputro), Ottawa, Ont.; Emily's House Children's Hospice (Rapoport), Toronto, Ont.; McMaster University (Seow), Hamilton, Ont.; BC Children's Hospital (Siden); Canuck Place Children's Hospice (Siden), Vancouver, BC; Children's Hospital of Eastern Ontario (Vadeboncoeur); Roger Neilson House (Vadeboncoeur), Ottawa, Ont
| | - Harold Siden
- Lawrence S. Bloomberg Faculty of Nursing (Widger, Brennenstuhl), University of Toronto; Hospital for Sick Children (Widger, Nelson, Rapoport, Gupta), Toronto, Ont.; Ottawa Hospital Research Institute (Tanuseputro); Department of Medicine (Tanuseputro), University of Ottawa; Bruyère Research Institute (Tanuseputro), Ottawa, Ont.; Emily's House Children's Hospice (Rapoport), Toronto, Ont.; McMaster University (Seow), Hamilton, Ont.; BC Children's Hospital (Siden); Canuck Place Children's Hospice (Siden), Vancouver, BC; Children's Hospital of Eastern Ontario (Vadeboncoeur); Roger Neilson House (Vadeboncoeur), Ottawa, Ont
| | - Chris Vadeboncoeur
- Lawrence S. Bloomberg Faculty of Nursing (Widger, Brennenstuhl), University of Toronto; Hospital for Sick Children (Widger, Nelson, Rapoport, Gupta), Toronto, Ont.; Ottawa Hospital Research Institute (Tanuseputro); Department of Medicine (Tanuseputro), University of Ottawa; Bruyère Research Institute (Tanuseputro), Ottawa, Ont.; Emily's House Children's Hospice (Rapoport), Toronto, Ont.; McMaster University (Seow), Hamilton, Ont.; BC Children's Hospital (Siden); Canuck Place Children's Hospice (Siden), Vancouver, BC; Children's Hospital of Eastern Ontario (Vadeboncoeur); Roger Neilson House (Vadeboncoeur), Ottawa, Ont
| | - Sumit Gupta
- Lawrence S. Bloomberg Faculty of Nursing (Widger, Brennenstuhl), University of Toronto; Hospital for Sick Children (Widger, Nelson, Rapoport, Gupta), Toronto, Ont.; Ottawa Hospital Research Institute (Tanuseputro); Department of Medicine (Tanuseputro), University of Ottawa; Bruyère Research Institute (Tanuseputro), Ottawa, Ont.; Emily's House Children's Hospice (Rapoport), Toronto, Ont.; McMaster University (Seow), Hamilton, Ont.; BC Children's Hospital (Siden); Canuck Place Children's Hospice (Siden), Vancouver, BC; Children's Hospital of Eastern Ontario (Vadeboncoeur); Roger Neilson House (Vadeboncoeur), Ottawa, Ont
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Lin SC, Chang KL, Huang MC. When and how do healthcare professionals introduce specialist palliative care to the families of children with life-threatening conditions in Taiwan? A qualitative study. J Pediatr Nurs 2022; 64:e136-e144. [PMID: 34980527 DOI: 10.1016/j.pedn.2021.12.004] [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: 01/24/2021] [Revised: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Specialist palliative care (SPC) is often needed to manage complex or refractory problems in children with life-threatening conditions during end-of-life. This study explores the perceptions of healthcare professionals (HPs) to determine the triggers leading to and experiences with introducing SPC among families of children with life-threatening conditions. METHODS A secondary analysis of 13 semi-structured interviews with HPs conducted from September 2019-June 2020 was carried out in a pediatric ward and a neonatal and pediatric intensive care unit in Taiwan. A thematic analysis was conducted. Competence Theory was used to guide the research questions and the interpretive framework. FINDINGS Seven nurses, four pediatricians, one psychologist, and one respiratory therapist were interviewed. The need for shared knowledge regarding wishes for care and end-of-life decision-making were found to be the indicators for introducing SPC, along with having a fear of causing harm to the family-professional relationship and the patient. HPs value harmony in the form of clarifying misconceptions, building trust, and holding the moral bottom line. The theme of 'seeking the competent self' encompasses the values and expectations related to improving skills and creating a sense of fulfillment as HPs achieve good quality care. DISCUSSION Discussions about SPC facilitate better communication and decision-making. Careful attention should be paid to the needs related to clarifying misconceptions and protecting the child's right to life when SPC is suggested. APPLICATION TO PRACTICE Communication, empathy, and conflict resolution training may be helpful with developing HP competencies related to introducing SPC.
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Affiliation(s)
- Shih-Chun Lin
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Kai-Ling Chang
- Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Mei-Chih Huang
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Nursing, National Tainan Junior College of Nursing, Tainan, Taiwan.
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Lysecki DL, Gupta S, Rapoport A, Rhodes E, Spruin S, Vadeboncoeur C, Widger K, Tanuseputro P. Children's Health Care Utilization and Cost in the Last Year of Life: A Cohort Comparison with and without Regional Specialist Pediatric Palliative Care. J Palliat Med 2022; 25:1031-1040. [PMID: 34981956 DOI: 10.1089/jpm.2021.0175] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Research remains inconclusive regarding the impact of specialist pediatric palliative care (SPPC) on health care utilization and cost. Objective: To better understand and quantify the impact of regional SPPC services on children's health care utilization and cost near end of life. Design: A retrospective cohort study used administrative databases to compare outcomes for child decedents (age 31 days to 19 years) from two similar regions in Ontario, Canada between 2010 and 2014, wherein one region had SPPC services (SPPC+) and the other did not (SPPC-). Measurements: Administrative databases provided demographics, health care utilization (days), and costs Canadian dollars) across settings in the last year of life, and location of death. Multivariable analyses produced relative rates (RRs) of health care days (acute and home care), intensive care unit (ICU) days, and health care costs (inpatient, outpatient, home, and physician) as well as the odds ratio (OR) of in-hospital death. Counterfactual analysis quantified the differences in utilization and costs. Results: A total of 807 children were included. On multivariable analysis, residence in the SPPC+ region (n = 363) was associated with fewer mean health care days (RR = 0.73; 95% confidence interval [CI]: 0.59-0.90); fewer mean ICU days (RR = 0.64; 95% CI: 0.44-0.94); lower mean health care costs (RR = 0.71; 95% CI: 0.56-0.91); and lower likelihood of in-hospital death (OR = 0.67; 95% CI: 0.49-0.92). The counterfactual analysis estimated mean reductions of 16.2 days (95% CI: 14.4-18.0) and $24,940 (95% CI: $21,703-$28,177) per child in the SPPC+ region. Conclusions: Although not a causal study, these results support an association between regional SPPC services and decreased health care utilization, intensity, and cost for children near end of life.
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Affiliation(s)
- David L Lysecki
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.,Quality of Life and Advanced Care, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Sumit Gupta
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
| | - Adam Rapoport
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Paediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada.,Emily's House, Toronto, Ontario, Canada
| | - Emily Rhodes
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sarah Spruin
- Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christina Vadeboncoeur
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Department of Pediatrics, CHEO, Ottawa, Ontario, Canada.,Roger Neilson House, Ottawa, Ontario, Canada
| | - Kimberley Widger
- Paediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontatio, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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7
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Zanin A, Brierley J, Latour JM, Gawronski O. End-of-life decisions and practices as viewed by health professionals in pediatric critical care: A European survey study. Front Pediatr 2022; 10:1067860. [PMID: 36704131 PMCID: PMC9872024 DOI: 10.3389/fped.2022.1067860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND AIM End-of-Life (EOL) decision-making in paediatric critical care can be complex and heterogeneous, reflecting national culture and law as well as the relative resources provided for healthcare. This study aimed to identify similarities and differences in the experiences and attitudes of European paediatric intensive care doctors, nurses and allied health professionals about end-of-life decision-making and care. METHODS This was a cross-sectional observational study in which we distributed an electronic survey to the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) members by email and social media. The survey had three sections: (i) 16 items about attitudes to EOL care, (ii) 14 items about EOL decisions, and (iii) 18 items about EOL care in practice. We used a 5-point Likert scale and performed descriptive statistical analysis. RESULTS Overall, 198 questionnaires were completed by physicians (62%), nurses (34%) and allied health professionals (4%). Nurses reported less active involvement in decision-making processes than doctors (64% vs. 95%; p < 0.001). As viewed by the child and family, the child's expected future quality of life was recognised as one of the most critical considerations in EOL decision-making. Sub-analysis of Northern, Central and Southern European regions revealed differences in the optimal timing of EOL decisions. Most respondents (n = 179; 90%) supported discussing organ donation with parents during EOL planning. In the sub-region analysis, differences were observed in the provision of deep sedation and nutritional support during EOL care. CONCLUSIONS This study has shown similar attitudes and experiences of EOL care among paediatric critical care professionals within European regions, but differences persist between European regions. Nurses are less involved in EOL decision-making than physicians. Further research should identify the key cultural, religious, legal and resource differences underlying these discrepancies. We recommend multi-professional ethics education to improve EOL care in European Paediatric Intensive Care.
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Affiliation(s)
- Anna Zanin
- Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Joe Brierley
- Critical Care Units, Great Ormond Street Hospital, London, United Kingdom
| | - Jos M Latour
- School of Nursing and Midwifery, University of Plymouth, Plymouth, United Kingdom
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Service, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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8
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Gibson-Smith D, Jarvis SW, Fraser LK. Place of death of children and young adults with a life-limiting condition in England: a retrospective cohort study. Arch Dis Child 2021; 106:780-785. [PMID: 33355156 PMCID: PMC8311108 DOI: 10.1136/archdischild-2020-319700] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 11/20/2020] [Accepted: 11/30/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess trends in place of death for children with a life-limiting condition and the factors associated with death at home or hospice rather than hospital. DESIGN Observational cohort study using linked routinely collected data. SETTING England. PATIENTS Children aged 0-25 years who died between 2003 and 2017. MAIN OUTCOME MEASURES Place of death: hospital, hospice, home. Multivariable multinomial logistic regression models. RESULTS 39 349 children died: 73% occurred in hospital, 6% in hospice and 16% at home. In the multivariable models compared with dying in a hospital: neonates were less likely, and those aged 1-10 years more likely, than those aged 28 days to <1 year to die in hospice. Children from all ethnic minority groups were significantly less likely to die in hospice, as were those in the most deprived group (RR 0.8, 95% CI 0.7 to 0.9). Those who died from 2008 were more likely than those who died earlier to die in a hospice.Children with cancer (RR 4.4, 95% CI 3.8 to 5.1), neurological (RR 2.0, 95% CI 1.7 to 2.3) or metabolic (RR 3.7, 95% CI 3.0 to 4.6) diagnoses were more likely than those with a congenital diagnosis to die in a hospice.Similar patterns were seen for clinical/demographic factors associated with home versus hospital deaths. CONCLUSIONS Most children with a life-limiting condition continue to die in the hospital setting. Further research on preferences for place of death is needed especially in children with conditions other than cancer. Paediatric palliative care services should be funded adequately to enable equal access across all settings, diagnostic groups and geographical regions.
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9
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Kaye EC, Weaver MS, DeWitt LH, Byers E, Stevens SE, Lukowski J, Shih B, Zalud K, Applegarth J, Wong HN, Baker JN, Ullrich CK. The Impact of Specialty Palliative Care in Pediatric Oncology: A Systematic Review. J Pain Symptom Manage 2021; 61:1060-1079.e2. [PMID: 33348034 PMCID: PMC9896574 DOI: 10.1016/j.jpainsymman.2020.12.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/03/2020] [Accepted: 12/06/2020] [Indexed: 02/08/2023]
Abstract
CONTEXT Children with cancer and their families have complex needs related to symptoms, decision-making, care planning, and psychosocial impact extending across the illness trajectory, which for some includes end of life. Whether specialty pediatric palliative care (SPPC) is associated with improved outcomes for children with cancer and their families is unknown. OBJECTIVE We conducted a systematic review following PRISMA guidelines to investigate outcomes associated with SPPC in pediatric oncology with a focus on intervention delivery, collaboration, and alignment with National Quality Forum domains. METHODS We searched PubMed, Embase, Scopus, Web of Science, and CINAHL databases from inception until April 2020 and reviewed references manually. Eligible articles were published in English, involved pediatric patients aged 0-18 years with cancer, and contained original data regarding patient and family illness and end-of-life experiences, including symptom management, communication, decision-making, quality of life, satisfaction, and healthcare utilization. RESULTS We screened 6682 article abstracts and 82 full-text articles; 32 studies met inclusion criteria, representing 15,635 unique children with cancer and 342 parents. Generally, children with cancer who received SPPC had improved symptom burden, pain control, and quality of life with decreased intensive procedures, increased completion of advance care planning and resuscitation status documentation, and fewer end-of-life intensive care stays with higher likelihood of dying at home. Family impact included satisfaction with SPPC and perception of improved communication. CONCLUSION SPPC may improve illness experiences for children with cancer and their families. Multisite studies utilizing comparative effectiveness approaches and validated metrics may support further advancement of the field.
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Affiliation(s)
- Erica C Kaye
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.
| | - Meaghann S Weaver
- Division of Pediatric Palliative Care, Children's Hospital and Medical Center, Omaha, Nebraska, USA
| | - Leila Hamzi DeWitt
- Department of Pediatrics, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Elizabeth Byers
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sarah E Stevens
- Departments of Psychosocial Oncology and Palliative Care and Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joe Lukowski
- The University of Nebraska, Omaha, Nebraska, USA
| | - Brandon Shih
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kristina Zalud
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jacob Applegarth
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hong-Nei Wong
- Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Christina K Ullrich
- Departments of Psychosocial Oncology and Palliative Care and Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Impact of palliative care on end-of-life care and place of death in children, adolescents, and young adults with life-limiting conditions: A systematic review. Palliat Support Care 2021; 19:488-500. [PMID: 33478607 DOI: 10.1017/s1478951520001455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the impact of palliative care (PC) on end-of-life (EoL) care and the place of death (PoD) in children, adolescents, and young adults with life-limiting conditions. METHOD Eight online databases (PubMed, Medline, EMBASE, Cochrane Library, CINAHL, Airiti, GARUDA Garba Rujukan Digital, and OpenGrey) from 2010 to February 5, 2020 were searched for studies investigating EoL care and the PoD for pediatric patients receiving and not receiving PC. RESULTS Of the 6,468 citations identified, 14 cohort studies and one case series were included. An evidence base of mainly adequate- and strong-quality studies shows that inpatient hospital PC, either with or without the provision of home and community PC, was found to be associated with a decrease in intensive care use and high-intensity EoL care. Conflicting evidence was found for the association between PC and hospital admissions, length of stay in hospital, resuscitation at the time of death, and the proportion of hospital and home deaths. SIGNIFICANCE OF RESULTS Current evidence suggests that specialist, multidisciplinary involvement, and continuity of PC are required to reduce the intensity of EoL care. Careful attention should be paid to the need for a longer length of stay in a medical setting late in life, and earlier EoL care discussion should take place with patients/caregivers, especially in regard to attempting resuscitation in toddlers, adolescents, and the young adult population. A lack of robust evidence has identified a gap in rigorous multisite prospective studies utilizing data collection.
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11
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Palumbo K, Koncicki ML. Pediatric Palliative Care and the PICU: Where We Have Been and Where We Are Going. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00230-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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12
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Coombs S, Aouad P, Jaaniste T. Factors Associated With the Location of Expected Pediatric Deaths in the Palliative Care Context. OMEGA-JOURNAL OF DEATH AND DYING 2020; 85:850-867. [PMID: 32938305 DOI: 10.1177/0030222820959941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Early planning and knowing which factors to consider when planning the location of death (LOD) of a palliative child, may help minimize the burden of hasty decision-making in the future, and may provide families with a sense of control. The current paper reviewed which factors were associated with pediatric LOD and further considered some emerging factors that should are important to better facilitate integrative planning. Three overarching areas of consideration related to pediatric LOD planning were identified including health service factors, familial factors and patient factors. Multiple sub-factor considerations are presented. Further, the paper presents a conceptual model of the factors found to be related to pediatric LOD planning. The limitations that exist with rigorously and empirically studying pediatric LOD preferences are apparent from the dearth of knowledge seen in the field. However, future studies should continue to examine such factors more closely to better understand the nuanced implications.
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Affiliation(s)
- Sandra Coombs
- Departments of Pain and Palliative Care, Sydney Children's Hospital - Randwick, Sydney, Australia
| | - Phillip Aouad
- Departments of Pain and Palliative Care, Sydney Children's Hospital - Randwick, Sydney, Australia
- Department of Pain, Sydney Children's Hospital - Randwick, Sydney, Australia
| | - Tiina Jaaniste
- Departments of Pain and Palliative Care, Sydney Children's Hospital - Randwick, Sydney, Australia
- Department of Pain, Sydney Children's Hospital - Randwick, Sydney, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
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13
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Al Mutair A, Al Ammary M, Brooks LA, Bloomer MJ. Supporting Muslim families before and after a death in neonatal and paediatric intensive care units. Nurs Crit Care 2019; 24:192-200. [PMID: 31124208 DOI: 10.1111/nicc.12434] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/11/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The death of a child is regarded as one of the most devastating events for a family. Families are reliant on nurses to not only provide end-of-life care but also to support and care for grieving families in a way that is sensitive to their cultural and religious needs and preferences. AIMS The aim of this study was to explore the perceived impact and influence of cultural diversity on how neonatal and paediatric intensive care nurses care for Muslim families before and after the death of infants/children. DESIGN A qualitative descriptive approach was used in this study, conducted in Saudi Arabia. METHODS Semi-structured interviews were used to gather data from a convenience sample of registered nurses working in neonatal and paediatric intensive care, with experience in providing end-of-life care. Interviews were conducted between July and November, 2018. Interviews were audio-recorded and transcribed for analysis. RESULTS Thirteen registered nurses participated; all were born overseas, identified with various faiths and spoke English in the workplace. A respect for diversity and care of the family was prioritized yet impacted by communication challenges. Caring and respect was demonstrated by facilitating important cultural and religious practices important in the Muslim faith. Self-care was identified as important, transcending the culturally diverse nature of the nursing workforce. CONCLUSIONS Significant challenges exist for a culturally diverse nursing workforce in providing care to a Saudi Muslim population of infants/children and families, before and after a death. Their overriding commitment to respect for others, and an openness to cultural diversity and difference, aided in overcoming the inherent challenges in providing culturally sensitive end-of-life care that meets the needs of Muslim families. These findings provide valuable insights for intensive care clinicians in other countries to address challenges associated with cultural diversity.
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Affiliation(s)
- Abbas Al Mutair
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia.,School of Nursing, Wollongong University, Wollongong, New South Wales, Australia.,Alfaisal University, Riyadh, Saudi Arabia
| | - Maram Al Ammary
- Prince Sultan Medical City, Cardiac Center, Riyadh, Saudi Arabia
| | - Laura A Brooks
- School of Nursing and Midwifery, Deakin University, Geelong, Melbourne, Australia
| | - Melissa J Bloomer
- School of Nursing and Midwifery, Deakin University, Geelong, Melbourne, Australia.,Centre for Quality and Patient Safety Research, Deakin University, Geelong, Melbourne, Australia
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14
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Widger K, Medeiros C, Trenholm M, Zuniga-Villanueva G, Streuli JC. Indicators Used to Assess the Impact of Specialized Pediatric Palliative Care: A Scoping Review. J Palliat Med 2018; 22:199-219. [PMID: 30526276 DOI: 10.1089/jpm.2018.0420] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Specialized pediatric palliative care programs aim to improve quality of life and ease distress of patients and their families across the illness trajectory. These programs require further development, which should be based on how they improve outcomes for patients, families, health care professionals, and the health care system. OBJECTIVE To identify and compare definitions of indicators used to assess the impact of specialized pediatric palliative care programs. DESIGN The scoping review protocol was prospectively registered on PROSPERO 2017 (CRD42017074090). DATE SOURCES MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Scopus, and Embase databases were searched from January 2000 to September 2018. Eligible studies included randomized controlled trials, experimental studies, or observational studies that compared specialized programs with usual care. Studies were excluded if most care recipients were older than 19 years or the article was not available in English, French, German, or Spanish. RESULTS Forty-six studies were included; one was a randomized controlled trial. We identified 82 different indicators grouped into 14 domains. The most common indicators included the following: location of death, length of stay in hospital, and number of hospital admissions. Only 22 indicators were defined identically in at least 2 studies. Only one study included children's perspectives in assessing indicators. CONCLUSIONS Many indicators were used to assess program outcomes with little definition consensus across studies. Development of a set of agreed-upon indicators to assess program impact concurrent with family and patient input is essential to advance research and practice in pediatric palliative care.
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Affiliation(s)
- Kimberley Widger
- 1 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,2 Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christina Medeiros
- 1 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Madeline Trenholm
- 1 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | - Jürg C Streuli
- 1 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,3 Pediatric Ethics and Palliative Care, University Children's Hospital Zurich, Zurich, Switzerland
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15
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Grimston M, Butler AE, Copnell B. Critical care nurses' experiences of caring for a dying child: A qualitative evidence synthesis. J Adv Nurs 2018; 74:1752-1768. [PMID: 29729652 DOI: 10.1111/jan.13701] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 02/27/2018] [Accepted: 04/04/2018] [Indexed: 11/30/2022]
Abstract
AIM To synthesize qualitative research examining the experience of critical care nurses caring for a dying child. BACKGROUND Caring for a dying child remains one of the most difficult aspects of nursing, potentially leading to personal and professional distress. A thorough understanding of this experience for critical care nurses allows for improved delivery of care and support for the nurse. DESIGN A qualitative evidence synthesis was undertaken, informed by Thomas and Harden's thematic synthesis methodology. DATA SOURCES Studies were retrieved from CINAHL Plus, Scopus, OVID Medline, and Embase, alongside hand-searching reference lists in February 2016. REVIEW METHODS Two reviewers independently assessed each study using a multistep screening process and performed critical appraisal of each included study. Data were extracted onto a predeveloped tool and analysed using thematic analysis. RESULTS There is a blurred line between the role of the nurse as a person or a professional while caring for the child and family throughout hospitalization and during and after the death. Each stage of care involves tasks and emotions that highlight the changing dominance of the nurse as either a person or professional. CONCLUSION Personal, interpersonal, and contextual factors affect delivery of care and impact of the death of the child on the critical care nurse. Reviewing individual and institutional practices could improve provision of care, interprofessional collaboration, and support provided to staff involved.
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Affiliation(s)
- Mitchell Grimston
- Education and Training Service, Nepean Blue Mountains Local Health District, Penrith, NSW, Australia
- Nepean Emergency Department, Penrith, NSW, Australia
| | - Ashleigh E Butler
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, UCL/Great, London, UK
- School of Nursing and Midwifery, Monash University, Melbourne, Australia
| | - Beverley Copnell
- School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
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16
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Butler AE, Hall H, Copnell B. Becoming a Team: The Nature of the Parent-Healthcare Provider Relationship when a Child is Dying in the Pediatric Intensive Care Unit. J Pediatr Nurs 2018; 40:e26-e32. [PMID: 29454506 DOI: 10.1016/j.pedn.2018.02.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To explore bereaved parents' perspectives of parent and staff roles in the pediatric intensive care unit when their child was dying, and their relationships with healthcare staff during this time. DESIGN AND METHODS Constructivist grounded theory was used to undertake this study. Semi-structured interviewers were conducted with 26 bereaved parents recruited from four Australian pediatric intensive care units. The constant comparative method, coupled with open, focused, and theoretical coding were used for data analysis. RESULTS Becoming a team explores the changes that occurred to the parent-healthcare provider relationship when parents realized their child was dying and attempted to become part of their child's care team. When the focus of care changed from 'life-saving' to 'end-of-life', parents' perspectives and desires of their and the healthcare providers' roles changed. Parents' attempted to reconstruct their roles to match their changing perspectives, which may or may not have been successful, depending on their ability to successfully negotiate these roles with healthcare providers. CONCLUSIONS Findings offer insights into parental understandings of both the parental and healthcare provider roles for parents of dying children in intensive care, and the ways in which the parent-healthcare provider relationships can influence and be influenced by changes to these roles. PRACTICE IMPLICATIONS Successful parent-healthcare provider relationships require an understanding of the parental and healthcare provider role from the parents' perspective. The meanings of the parental and healthcare provider roles should be explored with parents of dying children, and supported as much as possible to enable the development of a collaborative relationship.
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Affiliation(s)
- Ashleigh E Butler
- School of Nursing and Midwifery, Monash University, Clayton Campus, Wellington Road, Victoria 3800, Australia; Adult and Pediatric Intensive Care Unit, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia.
| | - Helen Hall
- School of Nursing and Midwifery, Monash University, Clayton Campus, Wellington Road, Victoria 3800, Australia
| | - Beverley Copnell
- School of Nursing and Midwifery, Monash University, Clayton Campus, Wellington Road, Victoria 3800, Australia
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17
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18
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Butler AE, Hall H, Copnell B. Bereaved parents' experiences of the police in the paediatric intensive care unit. Aust Crit Care 2018; 32:40-45. [PMID: 29571596 DOI: 10.1016/j.aucc.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND A child's death in the intensive care unit is often sudden and unexpected, requiring the involvement of the state coroner to investigate both the cause and the circumstances surrounding the death. This process often involves the police, who arrive in intensive care to identify the body and collect statements from the parents. At present, very little is known about parents' experiences of this process. OBJECTIVES To explore bereaved parents' experiences of police presence in intensive care, as part of routine coronial investigations. The findings arose from a larger study on bereaved parents' experiences of the death of a child in the intensive care unit. METHODS Secondary analysis of incidental data from a larger grounded theory study. Nine bereaved parents from two paediatric intensive care units (PICUs) mentioned police presence in the PICU during their original audio-recorded, semistructured interviews. These data were extracted, and thematic analysis techniques were used to identify key themes. RESULTS Three main concepts were identified with the parents' experiences: (i) timing of police interviews; (ii) the impacts of police presence; and (iii) the demeanour of the officers. Overall, the parents' experiences of police presence were negative. They felt that police arrived too soon after their child's death and took too long taking their statements, hindering their ability to say goodbye. The presence of police officers also made parents feel as though they were being accused of involvement in their child's death. Finally, several participants also experienced inappropriate or unsympathetic attitudes from the police officers attending their child's death. CONCLUSIONS Findings from our study indicate that parents' experiences of police presence in the PICU as part of a coronial investigation may be negative, leaving lasting impressions on their experiences of their child's death. These findings provide areas for improvements in care delivery and the treatment of newly bereaved parents during the early phases of a coronial investigation.
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Affiliation(s)
- Ashleigh E Butler
- School of Nursing and Midwifery, Monash University, Victoria, Australia; Adult and Paediatric Intensive Care Unit, Monash Health, Victoria, Australia.
| | - Helen Hall
- School of Nursing and Midwifery, Monash University, Victoria, Australia.
| | - Beverley Copnell
- School of Nursing and Midwifery, Monash University, Victoria, Australia.
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Nelson KE, Feinstein JA, Gerhardt CA, Rosenberg AR, Widger K, Faerber JA, Feudtner C. Emerging Methodologies in Pediatric Palliative Care Research: Six Case Studies. CHILDREN-BASEL 2018; 5:children5030032. [PMID: 29495384 PMCID: PMC5867491 DOI: 10.3390/children5030032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/13/2018] [Accepted: 02/16/2018] [Indexed: 12/17/2022]
Abstract
Given the broad focus of pediatric palliative care (PPC) on the physical, emotional, and spiritual needs of children with potentially life-limiting illnesses and their families, PPC research requires creative methodological approaches. This manuscript, written by experienced PPC researchers, describes issues encountered in our own areas of research and the novel methods we have identified to target them. Specifically, we discuss potential approaches to: assessing symptoms among nonverbal children, evaluating medical interventions, identifying and treating problems related to polypharmacy, addressing missing data in longitudinal studies, evaluating longer-term efficacy of PPC interventions, and monitoring for inequities in PPC service delivery.
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Affiliation(s)
- Katherine E Nelson
- Pediatric Advanced Care Team, Department of Paediatrics, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada.
| | - James A Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Children's Hospital Colorado, Aurora, CO 80045, USA.
- Division of General Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - Cynthia A Gerhardt
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, OH 43205, USA.
- Departments of Pediatrics and Psychology, The Ohio State University, Columbus, OH 43210, USA.
| | - Abby R Rosenberg
- Department of Pediatrics, University of Washington School of Medicine; Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA 98105, USA.
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA 98101, USA.
| | - Kimberley Widger
- Pediatric Advanced Care Team, Department of Paediatrics, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5T 1P8, Canada.
| | - Jennifer A Faerber
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Forjaz de Lacerda A, Gomes B. Trends in cause and place of death for children in Portugal (a European country with no Paediatric palliative care) during 1987-2011: a population-based study. BMC Pediatr 2017; 17:215. [PMID: 29273020 PMCID: PMC5741889 DOI: 10.1186/s12887-017-0970-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/12/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Children and adolescents dying from complex chronic conditions require paediatric palliative care. One aim of palliative care is to enable a home death if desired and well supported. However, there is little data to inform care, particularly from countries without paediatric palliative care, which constitute the majority worldwide. METHODS This is an epidemiological study analysing death certificate data of decedents aged between 0 and 17 years in Portugal, a developed Western European country without recognised provision of paediatric palliative care, from 1987 to 2011. We analysed death certificate data on cause and place of death; the main outcome measure was home death. Complex chronic conditions included cancer, cardiovascular, neuromuscular, congenital/genetic, respiratory, metabolic, gastro-intestinal, renal, and haematology/immunodeficiency conditions. Multivariate analysis determined factors associated with home death in these conditions. RESULTS Annual deaths decreased from 3268 to 572. Of 38,870 deaths, 10,571 were caused by complex chronic conditions, their overall proportion increasing from 23.7% to 33.4% (22.4% to 45.4% above age 1-year). For these children, median age of death increased from 0.5 to 4.32-years; 19.4% of deaths occurred at home, declining from 35.6% to 11.5%; factors associated with home death were year of death (adjusted odds ratio 0.89, 95% confidence interval 0.89-0.90), age of death (6-10 year-olds 21.46, 16.42-28.04, reference neonates), semester of death (October-March 1.18, 1.05-1.32, reference April-September), and cause of death (neuromuscular diseases 1.59, 1.37-1.84, reference cancer), with wide regional variation. CONCLUSIONS This first trend analysis of paediatric deaths in Portugal (an European country without paediatric palliative care) shows that palliative care needs are increasing. Children are surviving longer and, in contrast with countries where paediatric palliative care is thriving, there is a long-term trend of dying in hospital instead of at home. Age, diagnosis, season and region are associated with home death, and should be considered when planning services to support families choosing this option. Priorities should address needs of the youngest children, those with cancer, neuromuscular and cardiovascular conditions, as well as inequities related to place of residence.
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Affiliation(s)
- Ana Forjaz de Lacerda
- King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ UK
- Portuguese Institute of Oncology – Lisbon Centre, Paediatrics Department, Lisboa, Portugal
| | - Barbara Gomes
- King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ UK
- University of Coimbra, Faculty of Medicine, Coimbra, Portugal
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Suttle ML, Jenkins TL, Tamburro RF. End-of-Life and Bereavement Care in Pediatric Intensive Care Units. Pediatr Clin North Am 2017; 64:1167-1183. [PMID: 28941542 PMCID: PMC5747301 DOI: 10.1016/j.pcl.2017.06.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Most childhood deaths in the United States occur in hospitals. Pediatric intensive care clinicians must anticipate and effectively treat dying children's pain and suffering and support the psychosocial and spiritual needs of families. These actions may help family members adjust to their loss, particularly bereaved parents who often experience reduced mental and physical health. Candid and compassionate communication is paramount to successful end-of-life (EOL) care as is creating an environment that fosters meaningful family interaction. EOL care in the pediatric intensive care unit is associated with challenging ethical issues, of which clinicians must maintain a sound and working understanding.
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Affiliation(s)
- Markita L. Suttle
- Department of Critical Care Medicine, Nationwide Children's Hospital
| | - Tammara L. Jenkins
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Robert F. Tamburro
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
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22
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Duc JK, Herbert AR, Heussler HS. Paediatric palliative care and intellectual disability—A unique context. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2017; 30:1111-1124. [DOI: 10.1111/jar.12389] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Jacqueline K Duc
- Paediatric Palliative Care ServiceChildren's Health Queensland Australia
- Centre for Children's Health Ethics and LawQueensland Health Australia
- Faculty of MedicineUniversity of Queensland Brisbane Australia
| | - Anthony Robert Herbert
- Paediatric Palliative Care ServiceChildren's Health Queensland Australia
- Centre for Children's Health Ethics and LawQueensland Health Australia
- Faculty of MedicineUniversity of Queensland Brisbane Australia
| | - Helen S Heussler
- Paediatric Palliative Care ServiceChildren's Health Queensland Australia
- Faculty of MedicineUniversity of Queensland Brisbane Australia
- Mater Research InstituteUniversity of Queensland Brisbane Australia
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Butler AE, Hall H, Copnell B. The changing nature of relationships between parents and healthcare providers when a child dies in the paediatric intensive care unit. J Adv Nurs 2017; 74:89-99. [DOI: 10.1111/jan.13401] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ashleigh E. Butler
- School of Nursing and Midwifery; Monash University; Clayton Vic. Australia
| | - Helen Hall
- School of Nursing and Midwifery; Monash University; Clayton Vic. Australia
| | - Beverley Copnell
- School of Nursing and Midwifery; Monash University; Clayton Vic. Australia
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van der Geest IMM, Bindels PJE, Pluijm SMF, Michiels EMC, van der Heide A, Pieters R, Darlington ASE, van den Heuvel-Eibrink MM. Home-Based Palliative Care for Children With Incurable Cancer: Long-term Perspectives of and Impact on General Practitioners. J Pain Symptom Manage 2017; 53:578-587. [PMID: 28042078 DOI: 10.1016/j.jpainsymman.2016.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/09/2016] [Accepted: 09/25/2016] [Indexed: 11/23/2022]
Abstract
CONTEXT Although a large percentage of children with advanced-stage cancer die at home, remarkably little information is available regarding the experience of general practitioners (GPs) with respect to providing home-based palliative care to children with incurable cancer. OBJECTIVES The objective of this study was to explore the perspectives of GPs who care for children with advanced-stage cancer in a home-based setting. METHODS In this cross-sectional study, 144 GPs who provided home-based palliative care to 150 children with incurable cancer from 2001 through 2010 were invited to complete a questionnaire addressing their perspectives regarding: 1) symptom management, 2) collaboration with other health care professionals, 3) the child's death and care after death, and 4) impact of having provided palliative care, scored on distress thermometer (range 0-10). RESULTS A total of 112 GPs (78%) responded, and 91 GPs completed the questionnaire for 93 patients. The median interval between the child's death and completing the questionnaire was seven years. The most prevalent symptoms reported in the patients were fatigue (67%) and pain (61%). Difficulties with communicating with (14%), coordinating with (11%), collaborating with (11%), and contacting (2%) fellow members of the multidisciplinary treatment team were rare. Hectic (7%) and shocking (5%) situations and panic (2%) around the child's death were rare. GPs reported feelings of sadness (61%) and/or powerlessness (43%) around the time of the patient's death, and they rated their own distress level as relatively high during the terminal phase (median score 6, range 0-9.5). The majority of GPs (94%) reported that they ultimately came to terms with the child's death. CONCLUSION In general, GPs appear to be satisfied with the quality of home-based palliative care that they provide pediatric patients with incurable cancer. Communication among health care professionals is generally positive and is considered important. Finally, although the death of a pediatric patient has a profound impact on the GP, the majority of GPs eventually come to terms with the child's death.
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Affiliation(s)
- Ivana M M van der Geest
- Department of Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands; Princess Màxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | | | - Saskia M F Pluijm
- Department of Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands; Princess Màxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Erna M C Michiels
- Department of Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Rob Pieters
- Princess Màxima Center for Pediatric Oncology, Utrecht, The Netherlands
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Thornley S, Marshall RJ, Bach K, Koopu P, Reynolds G, Sundborn G, Ei WLSS. Sugar, dental caries and the incidence of acute rheumatic fever: a cohort study of Māori and Pacific children. J Epidemiol Community Health 2016; 71:364-370. [DOI: 10.1136/jech-2016-208219] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/04/2016] [Accepted: 10/26/2016] [Indexed: 11/03/2022]
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Abstract
OBJECTIVES Most deaths in U.S. PICUs occur after a decision has been made to limitation or withdrawal of life support. The objective of this study was to describe the clinical characteristics and outcomes of children whose families discussed limitation or withdrawal of life support with clinicians during their child's PICU stay and to determine the factors associated with limitation or withdrawal of life support discussions. DESIGN Secondary analysis of data prospectively collected from a random sample of children admitted to PICUs affiliated with the Collaborative Pediatric Critical Care Research Network between December 4, 2011, and April 7, 2013. SETTING Seven clinical sites affiliated with the Collaborative Pediatric Critical Care Research Network. PATIENTS Ten thousand seventy-eight children less than 18 years old, admitted to a PICU, and not moribund at admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Families of 248 children (2.5%) discussed limitation or withdrawal of life support with clinicians. By using a multivariate logistic model, we found that PICU admission age less than 14 days, reduced functional status prior to hospital admission, primary diagnosis of cancer, recent catastrophic event, emergent PICU admission, greater physiologic instability, and government insurance were independently associated with higher likelihood of discussing limitation or withdrawal of life support. Black race, primary diagnosis of neurologic illness, and postoperative status were independently associated with lower likelihood of discussing limitation or withdrawal of life support. Clinical site was also independently associated with likelihood of limitation or withdrawal of life support discussions. One hundred seventy-three children (69.8%) whose families discussed limitation or withdrawal of life support died during their hospitalization; of these, 166 (96.0%) died in the PICU and 149 (86.1%) after limitation or withdrawal of life support was performed. Of those who survived, 40 children (53.4%) were discharged with severe or very severe functional abnormalities, and 15 (20%) with coma/vegetative state. CONCLUSIONS Clinical factors reflecting type and severity of illness, sociodemographics, and institutional practices may influence whether limitation or withdrawal of life support is discussed with families of PICU patients. Most children whose families discuss limitation or withdrawal of life support die during their PICU stay; survivors often have substantial disabilities.
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Bloomer MJ, Endacott R, Copnell B, O'Connor M. 'Something normal in a very, very abnormal environment'--Nursing work to honour the life of dying infants and children in neonatal and paediatric intensive care in Australia. Intensive Crit Care Nurs 2015; 33:5-11. [PMID: 26687773 DOI: 10.1016/j.iccn.2015.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 09/15/2015] [Accepted: 09/17/2015] [Indexed: 11/24/2022]
Abstract
The majority of deaths of children and infants occur in paediatric and neonatal intensive care settings. For nurses, managing an infant/child's deterioration and death can be very challenging. Nurses play a vital role in how the death occurs, how families are supported leading up to and after the infant/child's death. This paper describes the nurses' endeavours to create normality amidst the sadness and grief of the death of a child in paediatric and neonatal ICU. Focus groups and individual interviews with registered nurses from NICU and PICU settings gathered data on how neonatal and paediatric intensive care nurses care for families when a child dies and how they perceived their ability and preparedness to provide family care. Four themes emerged from thematic analysis: (1) respecting the child as a person; (2) creating opportunities for family involvement/connection; (3) collecting mementos; and (4) planning for death. Many of the activities described in this study empowered parents to participate in the care of their child as death approached. Further work is required to ensure these principles are translated into practice.
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Affiliation(s)
- Melissa J Bloomer
- Monash University, School of Nursing and Midwifery, Building E, PO Box 527, Frankston, VIC 3199, Australia.
| | - Ruth Endacott
- Monash University, School of Nursing and Midwifery, 10 Chancellors Walk, Clayton Campus, Clayton, VIC 3800, Australia.
| | - Beverley Copnell
- Monash University, School of Nursing and Midwifery, 10 Chancellors Walk, Clayton Campus, Clayton, VIC 3800, Australia.
| | - Margaret O'Connor
- Monash University, School of Nursing and Midwifery, Building E, PO Box 527, Frankston, VIC 3199, Australia.
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Hung YN, Liu TW, Tang ST. Determinants of Hospital Death for Taiwanese Pediatric Cancer Decedents, 2001-2010. J Pain Symptom Manage 2015; 50:685-92. [PMID: 26162507 DOI: 10.1016/j.jpainsymman.2015.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 05/22/2015] [Accepted: 06/01/2015] [Indexed: 11/24/2022]
Abstract
CONTEXT Factors influencing pediatric cancer patients' place of death may have evolved with advances in medical and hospice care since earlier studies were done. OBJECTIVES To comprehensively analyze factors associated with hospital death in an unbiased population of pediatric cancer patients in Taiwan. METHODS This was a retrospective cohort study using administrative data for 1603 Taiwanese pediatric cancer patients who died in 2001-2010. Place of death was hypothesized to be associated with 1) patient sociodemographics and disease characteristics, 2) primary physician's specialty, 3) characteristics and health care resources at both the hospital and regional levels, and 4) historical trends. RESULTS Most Taiwanese pediatric cancer patients (87.4%) died in an acute care hospital. The probability of dying in hospital increased slightly over time, reaching significance only in 2009 (adjusted odds ratio [AOR], 95% CI: 2.84 [1.32-6.11]). Children were more likely to die in an acute care hospital if they resided in the most urbanized area, were diagnosed with leukemia or lymphoma (2.32 [1.39-3.87]), and received care from a pediatrician (1.58 [1.01-2.47]) in a nonprofit proprietary hospital (1.50 [1.01-2.24]) or large hospital, reaching significance for the third quartile (2.57 [1.28-5.18]) of acute care hospital beds. CONCLUSION Taiwanese pediatric cancer patients predominantly died in an acute care hospital with a slightly increasing trend of shifting place of death from home to hospital. Propensity for hospital death was determined by residential urbanization level, diagnosis, primary physician's specialty, and the primary hospital's characteristics and health care resources. Clinical interventions and health policies should ensure that resources are allocated to allow pediatric cancer patients to die in the place they and their parents prefer to achieve a good death and promote their parents' bereavement adjustment.
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Affiliation(s)
- Yen-Ni Hung
- School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan, Republic of China
| | - Siew Tzuh Tang
- School of Nursing, Chang Gung University, Tao-Yuan, Taiwan, Republic of China.
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Abstract
Hospice is an important provider of end of life care; many children who die of cancer enroll in hospice programs. How frequently such children remain in hospice to die at home, or disenroll from hospice and die in the hospital, has not been described. A child's location of death has important implications for quality of life and parental adaptation. This represents a subanalysis of a retrospective study of 202 consecutive oncology patients who died at a single center between January 1, 2006 and December 31, 2010. Of 95 children who enrolled in hospice, 82 had known location of death. Sixty (73%) died at home or an inpatient hospice unit, 15 (18%) died in the oncology unit, 5 (6%) died in the intensive care unit, and 2 (2%) died in the emergency department. The median length of hospice services was 41 days, twice the national median of 21 days reported in adults. One quarter of children disenrolled from hospice care, ultimately dying in an acute care setting. Further studies are warranted to explore the hospice experience in children, and to address modifiable factors that may impact a family's choice to withdraw from hospice care.
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Butler A, Hall H, Willetts G, Copnell B. Parents' experiences of healthcare provider actions when their child dies: an integrative review of the literature. J SPEC PEDIATR NURS 2015; 20:5-20. [PMID: 25443391 DOI: 10.1111/jspn.12097] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 10/21/2014] [Accepted: 10/26/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE To review, critique and synthesise current research studies that examine parental perceptions of healthcare provider actions during and after the death of a child. CONCLUSIONS Five main themes were synthesised from the literature: staff attitudes and affect; follow-up care and ongoing contact; communication; attending to the parents; and continuity of care. PRACTICE IMPLICATIONS This review helps to identify important aspects of paediatric end-of-life care as recognised by parents, with the intention of placing the family at the centre of any future end-of-life care education or policy/protocol development.
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Affiliation(s)
- Ashleigh Butler
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia; Adult and Paediatric Intensive Care Unit, Monash Health, Melbourne, Victoria, Australia
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