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Schneider K, Roll S, Tissen-Diabaté T, Bührer C, Garten L. Public Attitudes Toward Ethics and Practices in End-of-Life Decision-Making for Neonates. JAMA Netw Open 2024; 7:e2353264. [PMID: 38270948 PMCID: PMC10811557 DOI: 10.1001/jamanetworkopen.2023.53264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/05/2023] [Indexed: 01/26/2024] Open
Abstract
Importance Attitudes toward end-of-life decision-making in neonatology have been studied in physicians and other health care professionals and are mostly shaped by their clinical education and work experiences. In contrast, attitudes among the general public have not yet been investigated. Objective To assess (1) attitudes in the general public toward euthanasia and withdrawal of life-prolonging treatment in neonates with severe life-limiting conditions, (2) knowledge of current German recommendations, and (3) values in the German society regarding ethical issues and proxy decisions at the beginning of life. Design, Setting, and Participants This cross-sectional study was performed in Germany and used an exploratory design to analyze responses to an interview conducted by an independent, established commissioned polling institute in March and April 2022. Participants were 16 years or older, with German language fluency and comprehension and living in Germany. Main Outcomes and Measures Knowledge about recommendations for euthanasia and withdrawal of life-prolonging treatment as well as personal attitudes toward (1) euthanasia and withdrawal of life-prolonging treatment and (2) surrogate end-of-life decision-making for newborn infants were assessed. Results The study included 2116 participants (1077 females [50.9%]; mean [SD] age 52.1 [18.7] years). Of the participants, 16.8% (311 of 1851) reported knowing the German recommendations for euthanasia and withdrawal of life-prolonging treatment for neonates. Euthanasia and withdrawal of life-prolonging treatment were supported by 64.7% (1369 of 2116) and 77.9% (1649 of 2116) of respondents, respectively. Shared decision-making between parents and physicians for neonates in end-of-life situations was supported by 65.6% of participants (1388). In situations where shared decision-making was not possible, 73.4% of respondents (1019 of 1388) put the ultimate decision to the parents. The magnitude of the associations was low between sociodemographic factors and views on ethical issues and customary practices involved in end-of-life decisions for neonates. Conclusions and Relevance Results of this cross-sectional study suggested that most respondents were not aware of the national German recommendations for euthanasia and withdrawal of life-prolonging treatment for sick and extremely preterm newborns. When counseling parents of periviable newborns, clinicians may need to exert more effort in explaining the legal and ethical framework; a highly individualized approach is warranted.
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Affiliation(s)
- Katja Schneider
- Department of Neonatology, Gemeinnützige Gesellschaft der Franziskanerinnen zu Olpe, Marien-Hospital, Bonn, Germany
- Department of Neonatology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Stephanie Roll
- Institute of Social Medicine, Epidemiology and Health Economics, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Tatjana Tissen-Diabaté
- Institute of Social Medicine, Epidemiology and Health Economics, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Garten
- Department of Neonatology, Charité–Universitätsmedizin Berlin, Berlin, Germany
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Polakova K, Ahmed F, Vlckova K, Brearley SG. Parents' experiences of being involved in medical decision-making for their child with a life-limiting condition: A systematic review with narrative synthesis. Palliat Med 2024; 38:7-24. [PMID: 38053373 PMCID: PMC10798032 DOI: 10.1177/02692163231214414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Parental involvement in the decision-making processes about medical treatment for children with life-limiting conditions is recognised as good practice. Previous research highlighted factors affecting the decision-making process, but little is known about how parents experience their participation. AIM To explore how parents experience their participation in the process of decision-making about treatment and future care for their children with life-limiting conditions. DESIGN A systematically constructed review using narrative synthesis. The PRISMA guidelines were followed to report the findings. Databases Medline, EMBASE, SCOPUS, CINAHL and PsycINFO were searched up to December 2023. The study protocol was registered at PROSPERO (RN CRD42021215863). RESULTS From the initial 2512 citations identified, 28 papers met the inclusion criteria and were included in the review. A wide range of medical decisions was identified; stopping general or life-sustaining treatment was most frequent. Narrative synthesis revealed six themes: (1) Temporal aspects affecting the experience with decision-making; (2) Losing control of the situation; (3) Transferring the power to decide to doctors; (4) To be a 'good' parent and protect the child; (5) The emotional state of parents and (6) Sources of support to alleviate the parental experience. CONCLUSIONS Parental experiences with decision-making are complex and multifactorial. Parents' ability to effectively participate in the process is limited, as they are not empowered to do so and the circumstances in which the decisions are taking place are challenging. Healthcare professionals need to support parental involvement in an effective way instead of just formally asking them to participate.
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Affiliation(s)
- Kristyna Polakova
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
- Center for Palliative Care, Prague, Czech Republic
| | - Faraz Ahmed
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | | | - Sarah G Brearley
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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3
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Funkquist EL, Lindquist A, Edner A. A Qualitative Study of Parents' Experiences of Bonding in End-of-Life Care in a Neonatal Intensive Care Unit. J Perinat Neonatal Nurs 2023:00005237-990000000-00022. [PMID: 37967271 DOI: 10.1097/jpn.0000000000000780] [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: 11/17/2023]
Abstract
AIM To examine the parent's experiences of bonding in the care of newborns who were seriously ill during the neonatal period and did not survive. DESIGN Data were collected through 7 interviews with 10 parents whose infants were cared for and died in a neonatal intensive care unit. METHODS The interviews were pilot processed using inductive content analysis and then processed again using deductive content analysis with the attachment theory applied as a theoretical frame. RESULTS Three main themes emerged from the parents' descriptions: 1. The parents' relationship with the healthcare provider: an alliance between the parent and the healthcare provider can facilitate communication, for example, the use of proposals to promote parents' role in the care; 2. The parents' relationship with the infant: parents' wish to fulfill the role of a protective parent, and it is of importance for the parents' future well-being to take part in care and decision making; and 3. The parents' relationship with the own self: in this unknown situation, parents' expectations of parenthood are broken, and they experience feelings of shame and powerlessness. CONCLUSION The relationship between the parent and the healthcare provider affects how the parents bond with their child and their experiences of the healthcare.
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Affiliation(s)
- Eva-Lotta Funkquist
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Crouch EE, Damas C, Bartrug WC, Shamiyeh A, Scelfo M, Dreyfus M, Gano D, Segal S, Franck LS. Parents' Views on Autopsy, Organ Donation, and Research Donation After Neonatal Death. JAMA Netw Open 2023; 6:e2341533. [PMID: 37930699 PMCID: PMC10628732 DOI: 10.1001/jamanetworkopen.2023.41533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/24/2023] [Indexed: 11/07/2023] Open
Abstract
Importance Parents who experience neonatal loss have the option to participate in autopsy, organ donation, and research donation. However, clinicians are uncomfortable discussing autopsy and may not be aware of research and organ donation opportunities. Objective To capture the perspectives of parents who had experienced neonatal loss about autopsy, organ donation, and research donation. Design, Setting, and Participants This qualitative study used virtual focus groups with parents who attended a local bereavement support group in the US. Participants were recruited from Helping After Neonatal Death, a support group with a local chapter. Participants self-selected from an email request if they met the following criteria: aged 18 years or older, English speaking, at least 6 months elapsed since neonatal death, and access to a video conference device with internet. Focus groups took place between April and September 2021. The recorded sessions were analyzed using a grounded theory-informed approach by the research team that included parents with experience of neonatal loss. Data were analyzed from December 2021 through December 2022. Results A total of 14 mothers engaged in the focus group; 9 (75%) were aged 30 to 39 years, and 8 (66%) were White. The mothers were overall well educated. The first main theme grew from the lived experience of neonatal loss, specifically the importance of offering all parents the option to donate, rather than prejudging who would or would not be interested. Parents of neonates who die have few opportunities to parent that child and make loving decisions for them. Participants emphasized that the conversation about autopsy, organ donation, and research donation, albeit difficult, can offer a meaningful parenting experience. A second main theme that emerged related to how organ or tissue donation could provide additional meaning to a child's life. These choices contributed to building a legacy to honor their child's memory, which also helped with grief and coping with their loss. A third theme included recommendations to clinicians and health systems for improving communication, including written information for parents and communication training for health care professionals. Conclusions and Relevance In this qualitative study, parents who experienced neonatal loss endorsed the importance of offering parents the choice of autopsy, organ donation, or research donation with skillful and empathetic communication. They provided practical recommendations to improve communication and empower families.
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Affiliation(s)
- Elizabeth E. Crouch
- Department of Pediatrics, University of California San Francisco
- The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco
| | - Carlos Damas
- Department of Pediatrics, University of California San Francisco
| | | | - Anne Shamiyeh
- Helping After Neonatal Death of the Bay Area, Redwood City, California
| | - Meghan Scelfo
- Department of Pediatrics, University of California San Francisco
| | | | - Dawn Gano
- Division of Pediatric Neurology, Department of Neurology, Benioff Children’s Hospital, University of California San Francisco
| | - Summer Segal
- Department of Pediatrics, Stad Center for Pain Palliative and Integrative Medicine, University of California San Francisco
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Tatterton MJ, Fisher MJ. 'You have a little human being kicking inside you and an unbearable pain of knowing there will be a void at the end': A meta-ethnography exploring the experience of parents whose baby is diagnosed antenatally with a life limiting or life-threatening condition. Palliat Med 2023; 37:1289-1302. [PMID: 37129319 PMCID: PMC10548777 DOI: 10.1177/02692163231172244] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Parents of babies diagnosed with life limiting conditions in the perinatal period face numerous challenges. Considerations include the remainder of the pregnancy, delivery of the baby and decisions around care in the neonatal period. AIM To increase understanding of how parents experience the diagnosis of a life-limiting or life-threatening condition, during pregnancy and following the birth of their baby, by answering the question: 'what is known about the perinatal experiences of parents of babies with a life-limiting or life-threatening diagnosis?' DESIGN A meta-ethnography was conducted to synthesise findings from existing qualitative evidence. DATA SOURCES British Nursing Database, CINAHL, Medline, PsycINFO and Embase databases were searched in January 2023. FINDINGS Relationships between parents and their families and friends, and with professionals influence the needs and experiences of parents, which oscillate between positive and negative experiences, throughout parents' perinatal palliative care journey. Parents highlighted the need for control and a sense of normality relating to their parenting experience. Validation was central to the experience of parents at all stages of parenthood. Relationships between the parent and the baby were unwavering, underpinned with unconditional love. CONCLUSION Professionals, family members and friendship groups influence the experience, validating parents and their baby's identity and supporting parents in having a sense of control and normality by demonstrating empathy, and providing time and clear communication.
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Affiliation(s)
- Michael J Tatterton
- School of Nursing and Healthcare Leadership, Faculty of Health Studies, University of Bradford, Bradford, UK
- Bluebell Wood Children’s Hospice, North Anston, Sheffield, UK
- International Children’s Palliative Care Network, c/o Together for Short Lives, Bristol, UK
| | - Megan J Fisher
- School of Nursing and Healthcare Leadership, Faculty of Health Studies, University of Bradford, Bradford, UK
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6
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Mukherjee S, Richardson N, Beresford B. Hospital healthcare experiences of children and young people with life-threatening or life-shortening conditions, and their parents: scoping reviews and resultant conceptual frameworks. BMC Pediatr 2023; 23:366. [PMID: 37460965 PMCID: PMC10351142 DOI: 10.1186/s12887-023-04151-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 06/24/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Patient experience is a core component of healthcare quality. Patient-reported experience measures (PREMs) are increasingly used to assess this, but there are few paediatric PREMs. This paper reports the first stage of developing two such measures, one for children and young people (0-18 years) (CYP) with a life-threatening or life-shortening condition (LT/LSC), and one for their parents. It comprised parallel scoping reviews of qualitative evidence on the elements of health service delivery and care that matter to, or impact on, CYP (Review 1) and parents (Review 2). METHODS Medline and PsychINFO (1/1/2010 - 11/8/2020) and CINAHL Complete (1/1/2010 - 4/7/2020) were searched and records identified screened against inclusion criteria. A thematic approach was used to manage and analyse relevant data, informed by existing understandings of patient/family experiences as comprising aspects of staff's attributes, their actions and behaviours, and organisational features. The objective was to identity the data discrete elements of health service delivery and care which matter to, or impact on, CYP or parents which, when organised under higher order conceptual domains, created separate conceptual frameworks. RESULTS 18,531 records were identified. Sparsity of data on community-based services meant the reviews focused only on hospital-based (inpatient and outpatient) experiences. 53 studies were included in Review 1 and 64 in Review 2. For Review 1 (CYP), 36 discrete elements of healthcare experience were identified and organized under 8 higher order domains (e.g. staff's empathetic qualities; information-sharing/decision making; resources for socializing/play). In Review 2 (parents), 55 elements were identified and organized under 9 higher order domains. Some domains were similar to those identified in Review 1 (e.g. professionalism; information-sharing/decision-making), others were unique (e.g. supporting parenting; access to additional support). CONCLUSIONS Multiple and wide-ranging aspects of the way hospital healthcare is organized and delivered matters to and impacts on CYP with LT/LSCs, and their parents. The aspects that matter differ between CYP and parents, highlighting the importance of measuring and understanding CYP and parent experience seperately. These findings are key to the development of patient/parent experience measures for this patient population and the resultant conceptual frameworks have potential application in service development.
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Affiliation(s)
- Suzanne Mukherjee
- Social Policy Research Unit, School of Business and Society, University of York, York, YO10 5ZF, UK.
| | - Natalie Richardson
- Social Policy Research Unit, School of Business and Society, University of York, York, YO10 5ZF, UK
| | - Bryony Beresford
- Social Policy Research Unit, School of Business and Society, University of York, York, YO10 5ZF, UK
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7
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Nieuwenhuijse AM, Willems DL, van Goudoever JB, Olsman E. Parent perspectives on the assessment of quality of life of their children with profound intellectual and multiple disabilities in the Netherlands. RESEARCH IN DEVELOPMENTAL DISABILITIES 2023; 139:104536. [PMID: 37269577 DOI: 10.1016/j.ridd.2023.104536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Assessing Quality of Life (QoL) of persons with profound intellectual and multiple disabilities (PIMD) is challenging, yet QoL plays an important role in medical decision-making processes concerning persons with PIMD. The perspectives of parents of children with PIMD on the assessment of their QoL have not been studied. AIM To explore the perspectives of parents on the assessment of QoL of their children. METHODS We conducted a qualitative study, forming three focus groups with 22 parents of children with PIMD to explore their views on what is necessary to assess QoL of their children and subsequently, who is best suited to assess QoL. RESULTS Parents describe a long-term relationship of the assessor with family (child and parents), with trust as an important aspect, as a requirement to assess QoL. Parents consider family members, preferably the parents themselves as the best assessors of QoL, followed by siblings. Professional caregivers, mostly mentioned by name, are considered the next alternative. Most parents thought that physicians do not know the child well enough to assess their QoL. CONCLUSIONS In conclusion, the parents of children with PIMD in our study consider trust and a long-term relationship essential for assessing QoL.
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Affiliation(s)
- A M Nieuwenhuijse
- Department of Ethics, Law and Humanities, Amsterdam UMC, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; Omega, Day Care Centre for Persons with PIMD, Amsterdam, the Netherlands.
| | - D L Willems
- Department of Ethics, Law and Humanities, Amsterdam UMC, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - J B van Goudoever
- Amsterdam UMC University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Department of Paediatrics, Amsterdam, the Netherlands
| | - E Olsman
- Section of Spiritual Care & Chaplaincy Studies, Department of Mediating Good Life, Protestant Theological University, Groningen, the Netherlands
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8
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Tadros HJ, Saidi A, Rawlinson AR, Cattier C, Black EW, Rackley J, Breault L, Pietra BA, Fricker FJ, Gupta D. Assessment of parental decision making in congenital heart disease, cardiomyopathy and heart transplantation: an observational study analysing decisional characteristics and preferences. Arch Dis Child 2023:archdischild-2022-324373. [PMID: 36732035 DOI: 10.1136/archdischild-2022-324373] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE We explore shared decision making (DM) in guardians of children with heart disease by assessing the desired weight of influence on DM and factors that may alter the relative weight of parent or medical team influence. METHODS Guardians of patients <21 years and admitted >1 week in the paediatric cardiac intensive care unit (PCICU) were recruited. Twelve vignettes were designed including technical (antibiotic selection, intubation, peripherally inserted central catheter placement, ventricular assist device placement, heart transplant, organ rejection, heart rhythm abnormalities and resuscitation effort) and non-technical vignettes (cessation of life-sustaining therapies, depression treatment, obesity and palliative care referral). Participants responded to questions on DM characteristics and one question querying preference for relative weight of parent or medical team influence on DM. RESULTS Of 209 participants approached, 183 were included. Most responded with equal desire of medical team and parental influence on DM in all vignettes (range 41.0%-66.7%). Technical scenarios formed one cluster based on DM characteristics, compared with non-technical scenarios. Factors that increase the relative weight of parental influence on DM include desired input and involvement in big-picture goals (OR 0.274, CI [0.217 to 0.346]; OR 0.794, CI [0.640 to 0.986]). Factors that increase the relative weight of medical team influence on DM include perception of medical expertise needed (OR 1.949 [1.630 to 2.330]), urgency (OR 1.373 [1.138 to 1.658]), benefit (OR 1.415 [1.172 to 1.710]), number of PCICU admissions (OR 1.134 [1.024 to 1.256]) and private insurance (OR 1.921 [1.144 to 3.226]). CONCLUSION Although factors may alter the weight of influence on DM, most parents desire equal parental and medical team influence on DM.
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Affiliation(s)
- Hanna J Tadros
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Arwa Saidi
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Alana R Rawlinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Celine Cattier
- Department of Palliative Care, University of Florida, Gainesville, Florida, USA
| | - Erik W Black
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Jennifer Rackley
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Leah Breault
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Biagio A Pietra
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Fredrick J Fricker
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Dipankar Gupta
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA .,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
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9
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DiDomizio PG, Millar MM, Olson L, Murphy N, Moore D. Palliative Care Needs Assessment for Pediatric Complex Care Providers. J Pain Symptom Manage 2023; 65:73-80. [PMID: 36384179 PMCID: PMC10445479 DOI: 10.1016/j.jpainsymman.2022.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 11/02/2022] [Accepted: 11/06/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT Children with medical complexity (CMC) are often cared for by both complex care and palliative care pediatric teams. No prior research has investigated the relationship between these two disciplines. OBJECTIVES The purpose of this article is to investigate challenges that complex care programs face in caring for children with medical complexity (CMC), as well as to explore whether identified challenges could be met through collaboration with pediatric palliative care or additional training for complex care teams. METHODS Medical providers who self-identified as providing clinical care to children with medical complexity were asked to complete an online anonymous survey. Subjects were recruited through a Complex Care listerv. Data were analyzed using descriptive statistics. RESULTS 85 subjects completed the survey, of whom 87.1% (n=74) were physicians, and 12.0% (n=11) were nurse practitioners. Subjects reported several challenges in caring for CMC, including symptom management, establishing goals of care, advance care planning, and coordination of care. A majority of subjects reported benefitting from palliative care consultative assistance in each subject area. Most subjects described their relationship with palliative care as a close partnership with frequent overlap. CONCLUSIONS The evolving field of pediatric complex care is associated with an array of challenges in caring for CMC. Many of these challenges include competency areas where palliative care providers receive concerted training. Our research suggests greater palliative care involvement in the CMC population can benefit complex care teams and patients, given the expertise palliative providers can bring to the population and the discipline of complex care.
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Affiliation(s)
- P Galen DiDomizio
- Department of Pediatrics (P .D.), Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Morgan M Millar
- Department of Internal Medicine (M. M.), University of Utah School of Medicine, Salt Lake City, Utah
| | - Lenora Olson
- Department of Family Medicine (L. O.), University of Utah School of Medicine, Salt Lake City, Utah
| | - Nancy Murphy
- Department of Pediatrics (N, M., D. M.), University of Utah School of Medicine, Capecchi Drive SLC Utah
| | - Dominic Moore
- Department of Pediatrics (N, M., D. M.), University of Utah School of Medicine, Capecchi Drive SLC Utah
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10
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Lin M, Sayeed S, DeCourcey DD, Wolfe J, Cummings C. The Case for Advance Care Planning in the NICU. Pediatrics 2022; 150:189893. [PMID: 36321383 DOI: 10.1542/peds.2022-057824] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/06/2022] Open
Abstract
Many NICUs have reached an inflection point where infant deaths following limitation of life-sustaining treatments outnumber those following unsuccessful resuscitations, and many infants who survive continue to require intensive supports. Families of such infants with serious illness may benefit from a standardized, process-oriented approach in decisional-support. Advance care planning (ACP), or communication that supports patients, or their surrogate decision-makers, in sharing values, goals, and preferences for future medical care, is recognized as a valuable strategy in supporting adults with serious and chronic illness. Although the role of ACP in older children and adolescents is evolving, its utility has not been systematically explored in the perinatal context. This article builds a case for formalizing a role for ACP in the NICU by defining ACP and appraising recent outcomes research, reviewing the current state of parental needs for decisional support and serious illness in the NICU, and describing how ACP may address current limitations in primary and specialty pediatric palliative care and challenges for decision-making in the newborn period.
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Affiliation(s)
- Matthew Lin
- Pediatric Palliative Care Program, Children's National Medical Center, Washington, District of Columbia
| | | | | | - Joanne Wolfe
- Departments of Psychosocial Oncology and Palliative Care and Pediatrics, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
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11
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Syltern J, Ursin L, Solberg B, Støen R. Postponed Withholding: Balanced Decision-Making at the Margins of Viability. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:15-26. [PMID: 33998962 DOI: 10.1080/15265161.2021.1925777] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support into an ethical dilemma. Shared decision-making with parents has gained ground. However, the need to start immediate life support and the ensuing difficulty of withdrawing treatment stands in tension with the possibility of a fair decision-making process. Both the parental "instinct of saving" and "withdrawal resistance" involved can preclude shared decision-making. To help health care personnel and empower parents, we propose a novel approach labeled "postponed withholding." In the absence of a prenatal advance directive, life support is started at birth, followed by planned redirection to palliative care after one week, unless parents, after a thorough counseling process, actively ask for continued life support. Despite the emotional challenges, this approach can facilitate ethically balanced decision-making processes in the gray zone.
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Affiliation(s)
- Janicke Syltern
- Norwegian University of Science and Technology
- St Olavs Hospital University Hospital in Trondheim
| | - Lars Ursin
- The Norwegian University of Science and Technology
| | | | - Ragnhild Støen
- Norwegian University of Science and Technology
- St Olavs Hospital University Hospital in Trondheim
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12
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Khalid F, Ng Voon SI, Ong LC, Lim WK, Li L, Adnan A, Ganesan V, Teh CM, Fong CY. Advance care plan discussion among parents of children with cerebral palsy. Dev Med Child Neurol 2022; 64:1025-1033. [PMID: 35213736 DOI: 10.1111/dmcn.15184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/28/2022]
Abstract
AIM To evaluate parental perception of advance care plan (ACP) discussions in families of Malaysian children with bilateral cerebral palsy (CP) classified in Gross Motor Function Classification System levels IV or V for (1) acceptance of the ACP discussion, (2) feedback on the usefulness of ACP discussion, and (3) exploration of possible factors related to parental acceptance of ACP. METHOD This was a prospective pre- and post-ACP discussion questionnaire study for parents of children with bilateral CP. RESULTS Sixty-nine patients were recruited to the study; 64 (93%) had at least one additional comorbidity. The median age was 8 years (interquartile range 5 years 1 month-11 years 6 months). Fifty-seven (82.6%) parents found the ACP discussion acceptable, and most reported positive feedback on various components of the discussion (88.4-97.1%). One-third of participants were not comfortable discussing end-of-life care plans. On multivariate analysis, parents who were comfortable discussing end-of-life care plans were more likely to find the ACP discussion acceptable (odds ratio 27.78, 95% confidence interval 2.9-265.1, p = 0.004). INTERPRETATION Most parents of Malaysian children with bilateral CP reported the ACP discussion as both acceptable and beneficial. Parents need to be comfortable about discussing end-of-life care plans for their child to enable the ACP discussion to be an acceptable experience.
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Affiliation(s)
- Farah Khalid
- Paediatric Pain and Palliative Care Unit, Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Swee Im Ng Voon
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.,Paediatric Department, Penang General Hospital, Penang, Malaysia
| | - Lai Choo Ong
- Division of Paediatric Neurology, Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Wei Kang Lim
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Limin Li
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Azirah Adnan
- Division of Paediatric Neurology, Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | | | - Chee Ming Teh
- Paediatric Department, Penang General Hospital, Penang, Malaysia
| | - Choong Yi Fong
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
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13
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Linebarger JS, Johnson V, Boss RD, Linebarger JS, Collura CA, Humphrey LM, Miller EG, Williams CSP, Rholl E, Ajayi T, Lord B, McCarty CL. Guidance for Pediatric End-of-Life Care. Pediatrics 2022; 149:186860. [PMID: 35490287 DOI: 10.1542/peds.2022-057011] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The final hours, days, and weeks in the life of a child or adolescent with serious illness are stressful for families, pediatricians, and other pediatric caregivers. This clinical report reviews essential elements of pediatric care for these patients and their families, establishing end-of-life care goals, anticipatory counseling about the dying process (expected signs or symptoms, code status, desired location of death), and engagement with palliative and hospice resources. This report also outlines postmortem tasks for the pediatric team, including staff debriefing and bereavement.
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Affiliation(s)
- Jennifer S Linebarger
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri, Kansas City, School of Medicine, Kansas City, Missouri
| | - Victoria Johnson
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Renee D Boss
- Department of Pediatrics, Johns Hopkins University School of Medicine, Berman Institute of Bioethics, Baltimore, Maryland
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14
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Gawronski O, Sansone V, Cancani F, Di Nardo M, Rossi A, Gagliardi C, De Ranieri C, Satta T, Dall'Oglio I, Tiozzo E, Alvaro R, Raponi M, Cecchetti C. Implementation of paediatric intensive care unit diaries: Feasibility and opinions of parents and healthcare providers. Aust Crit Care 2022; 36:370-377. [PMID: 35305896 DOI: 10.1016/j.aucc.2022.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 01/22/2022] [Accepted: 01/23/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND The implementation of paediatric intensive care unit (PICU) diaries has been reported as feasible in routine care. To date no feasibility study has compared PICU healthcare providers' (HCPs) and parents' opinions on this tool. OBJECTIVES The aim of this study is to describe the feasibility and perception of PICU diaries in an Italian PICU from the point of view of parents and HCPs. METHODS This is a single-centre, prospective, observational study conducted in a tertiary care paediatric hospital from August 2020 to May 2021. Children admitted to the emergency department PICU, intubated, and sedated for ≥48 h were enrolled. To explore their perceptions and attitudes with the PICU diary, parents were interviewed at 30 days from their child's discharge from the PICU, whereas PICU HCPs were surveyed at the end of the study. Data were analysed as proportions for categorical variables and means and medians for continuous variables according to the distribution, whereas qualitative data were summarised in categories by two independent researchers. RESULTS Twenty families were enrolled in this study. A total of 275 daily PICU diary entries were collected. Children's median age was 9 years (interquartile range = 2-13.25), and the length of stay ranged from 6 to 39 days. PICU diary applicability was rated high by parents and HCPs (>8 on a 1-10 Likert scale). Parents and HCPs perceived PICU diaries as beneficial for communication between staff and families, for parents by expressing their emotions and for staff by becoming aware of how parents experienced their child's admission. Reported barriers were the lack of a private environment, the risk of exposure to public reading, and PICU workload. CONCLUSIONS PICU diaries were feasible and perceived as beneficial both by parents and HCPs. Future research is warranted to understand the effect of PICU diaries on post-PICU outcomes.
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Affiliation(s)
- Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital, IRCCS, P.zza S. Onofrio 4, Rome, Italy.
| | - Vincenza Sansone
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital, IRCCS, P.zza S. Onofrio 4, Rome, Italy; Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Federica Cancani
- Pediatric Intensive Care Unit, Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Angela Rossi
- Clinical Psychology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Chiara Gagliardi
- Pediatric Intensive Care Unit, Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | | | - Tiziana Satta
- Pediatric Intensive Care Unit, Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Immacolata Dall'Oglio
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital, IRCCS, P.zza S. Onofrio 4, Rome, Italy.
| | - Emanuela Tiozzo
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital, IRCCS, P.zza S. Onofrio 4, Rome, Italy.
| | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | | | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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15
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Personalized communication with parents of children born at less than 25 weeks: Moving from doctor-driven to parent-personalized discussions. Semin Perinatol 2022; 46:151551. [PMID: 34893335 DOI: 10.1016/j.semperi.2021.151551] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Communication with parents is an essential component of neonatal care. For extremely preterm infants born at less than 25 weeks, this process is complicated by the substantial risk of mortality or major morbidity. For some babies with specific prognostic factors, the majority die. Although many of these deaths occur after admission to the intensive care unit, position statements have focused on communication during the prenatal consultation. This review takes a more comprehensive approach and covers personalized and parent-centered communication in the clinical setting during three distinct yet inter-related phases: the antenatal consultation, the neonatal intensive care hospitalization, and the dying process (when this happens). We advocate that a 'one-size-fits-all' communication model focused on standardizing information does not lead to partnerships. It is possible to standardize personalized approaches that recognize and adapt to parental heterogeneity. This can help clinicians and parents build effective partnerships of trust and affective support to engage in personalized decision-making. These practices begin with self-reflection on the part of the clinician and continue with practical frameworks and stepwise approaches supporting personalization and parent-centered communication.
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16
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Abstract
Rationale: The decision whether to initiate or forgo long-term ventilation for children can be difficult and impactful. However, little has been published on the informational and decisional needs of families facing this decision.Objectives: To assess what families with children with chronic respiratory failure and life-limiting conditions need and want for informed decision-making.Methods: English- and Spanish-speaking parents who were facing (contemporaneous decision makers) or had previously faced (former decision makers) a decision regarding invasive or noninvasive long-term ventilation for their children were recruited using convenience sampling. Patients who were older and cognitively capable also were invited to participate. We performed semistructured interviews using an open-ended interview guide developed de novo to assess parents' decisional needs and experiences. Qualitative data analysis used a thematic approach based on framework analysis, and thematic saturation was a goal.Results: A sample of 44 parents and 2 patients from 43 families was interviewed. All contemporaneous decision makers (n = 28) favored or believed that they would choose long-term ventilation. Fifteen of 16 former decision makers chose long-term ventilation. Thematic saturation was achieved from the perspective of parents who favored or chose long-term ventilation. Four domains were identified: parents' emotional and psychological experiences with decision-making, parents' informational needs, parents' communication and decision support needs, and parents' views on the option not to initiate long-term ventilation. For most parents, making a decision regarding long-term ventilation was stressful, even though they articulated goals and values that could/did guide their decision-making. In general, parents wanted comprehensive information, including what life would be like at home for the child and the family. They wanted their medical providers to be honest, tactful, patient, and supportive. Parents reported that they felt being presented with the option not to initiate was acceptable.Conclusions: In this study, we identified specific informational and decision-making needs regarding long-term ventilation that parents facing decisions feel are important. These data suggest that providers should present families with comprehensive, balanced information on the impact of long-term ventilation and, when the child has a profoundly serious and life-limiting condition, explore the option not to initiate long-term ventilation.
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17
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Mitchell S, Bennett K, Morris A, Slowther AM, Coad J, Dale J. Achieving beneficial outcomes for children with life-limiting and life-threatening conditions receiving palliative care and their families: A realist review. Palliat Med 2020; 34:387-402. [PMID: 31431129 PMCID: PMC7074600 DOI: 10.1177/0269216319870647] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Palliative care for children and young people is a growing global health concern with significant resource implications. Improved understanding of how palliative care provides benefits is necessary as the number of children with life-limiting and life-threatening conditions rises. AIM The aim is to investigate beneficial outcomes in palliative care from the perspective of children and families and the contexts and hidden mechanisms through which these outcomes can be achieved. DESIGN This is a systematic realist review following the RAMESES standards. A protocol has been published in PROSPERO (registration no: CRD42018090646). DATA SOURCES An iterative literature search was conducted over 2 years (2015-2017). Empirical research and systematic reviews about the experiences of children and families in relation to palliative care were included. RESULTS Sixty papers were included. Narrative synthesis and realist analysis led to the proposal of context-mechanism-outcome configurations in four conceptual areas: (1) family adaptation, (2) the child's situation, (3) relationships with healthcare professionals and (4) access to palliative care services. The presence of two interdependent contexts, the 'expert' child and family and established relationships with healthcare professionals, triggers mechanisms, including advocacy and affirmation in decision-making, which lead to important outcomes including an ability to place the emphasis of care on lessening suffering. Important child and family outcomes underpin the delivery of palliative care. CONCLUSION Palliative care is a complex, multifactorial intervention. This review provides in-depth understanding into important contexts in which child and family outcomes can be achieved so that they benefit from palliative care and should inform future service development and practice.
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Affiliation(s)
- Sarah Mitchell
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Karina Bennett
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Andrew Morris
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Jane Coad
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
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18
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Dreesens D, Veul L, Westermann J, Wijnands N, Kremer L, van der Weijden T, Verhagen E. The clinical practice guideline palliative care for children and other strategies to enhance shared decision-making in pediatric palliative care; pediatricians' critical reflections. BMC Pediatr 2019; 19:467. [PMID: 31783822 PMCID: PMC6883587 DOI: 10.1186/s12887-019-1849-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 11/21/2019] [Indexed: 11/10/2022] Open
Abstract
Background Because of practice variation and new developments in palliative pediatric care, the Dutch Association of Pediatrics decided to develop the clinical practice guideline (CPG) palliative care for children. With this guideline, the association also wanted to precipitate an attitude shift towards shared decision-making (SDM) and therefore integrated SDM in the CPG Palliative care for children. The aim was to gain insight if integrating SDM in CPGs can potentially encourage pediatricians to practice SDM. Its objectives were to explore pediatricians’ attitudes and thoughts regarding (1) recommendations on SDM in CPGs in general and the guideline Palliative care for children specifically; (2) other SDM enhancing strategies or tools linked to CPGs. Methods Semi-structured face-to-face interviews. Pediatricians (15) were recruited through purposive sampling in three university-based pediatric centers in the Netherlands. The interviews were audio-recorded and transcribed verbatim, coded by at least two authors and analyzed with NVivo. Results Some pediatricians considered SDM a skill or attitude that cannot be addressed by clinical practice guidelines. According to others, however, clinical practice guidelines could enhance SDM. In case of the guideline Palliative care for children, the recommendations needed to focus more on how to practice SDM, and offer more detailed recommendations, preferring a recommendation stating multiple options. Most interviewed pediatricians felt that patient decisions aids were beneficial to patients, and could ensure that all topics relevant to the patient are covered, even topics the pediatrician might not consider him or herself, or deems less important. Regardless of the perceived benefit, some pediatricians preferred providing the information themselves instead of using a patient decision aid. Conclusions For clinical practice guidelines to potentially enhance SDM, guideline developers should avoid blanket recommendations in the case of preference sensitive choices, and SDM should not be limited to recommendations on non-treatment decisions. Furthermore, preference sensitive recommendations are preferably linked with patient decision aids.
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Affiliation(s)
- Dunja Dreesens
- Department of Family Medicine, Maastricht University/School CAPHRI, P.O. Box 6166200, MD, Maastricht, the Netherlands. .,Knowledge Institute of the Federation of Medical Specialists, Utrecht, the Netherlands.
| | - Lotte Veul
- GGD-regio Utrecht, Utrecht, the Netherlands
| | | | - Nicole Wijnands
- Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Leontien Kremer
- Department of Pediatrics, Emma Children's Hospital/Amsterdam UMC, Amsterdam, the Netherlands.,Princess Maxima Centre, Utrecht, the Netherlands
| | - Trudy van der Weijden
- Department of Family Medicine, Maastricht University/School CAPHRI, P.O. Box 6166200, MD, Maastricht, the Netherlands
| | - Eduard Verhagen
- University of Groningen, Groningen, the Netherlands.,Beatrix Children's Hospital/University Medical Centre Groningen, Groningen, the Netherlands
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19
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Marland E, Davies B. In the child's best interests: should life be sustained when further treatment is futile? Nurs Child Young People 2019; 31:23-27. [PMID: 31637896 DOI: 10.7748/ncyp.2019.e1107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2019] [Indexed: 06/10/2023]
Abstract
The aim of this article is to explore the concept of medical futility and the withdrawal of care for children in intensive care units. There have been several recent cases where medical staff have considered that there was no possibility of recovery for a child, yet their clinical judgments were challenged by the parents. The private anguish of these families became public, social media heightened emotions and this was followed by political and religious intrusion. Innovations in medical treatment and technological advances raise issues for all those involved in the care of children and young people especially when decisions need to be made about end of life care. Healthcare professionals have a moral and legal obligation to determine when treatment should cease in cases where it is determined to be futile. The aim should be to work collaboratively with parents but all decisions must be made in the best interests of the child. However, medical staff and parents may have differing opinions about care decisions. In part, this may be as a result of their unique relationships with the child and different understanding of the extent to which the child is in discomfort or can endure pain.
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Affiliation(s)
- Emma Marland
- Neonatal department, Royal Victoria Infirmary, Newcastle upon Tyne, England
| | - Barbara Davies
- Children's nursing, University of Northumbria, Newcastle upon Tyne, England
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20
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Sidgwick P, Fraser J, Fortune PM, McCulloch R. Parallel planning and the paediatric critical care patient. Arch Dis Child 2019; 104:994-997. [PMID: 30705081 DOI: 10.1136/archdischild-2018-315222] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 12/02/2018] [Accepted: 12/21/2018] [Indexed: 11/03/2022]
Abstract
A growing number of children with life-limiting conditions (LLCs) are being cared for in paediatric critical care (PCC) settings. Children with LLCs admitted to PCC are at a high risk of developing complications and many die after prolonged admissions. Relatively few of these patients and their parents or carers have had documented discussions about their wishes for care in the event of a serious clinical deterioration before admission to PCC. There is a need for improved understanding of (1) how parents arrive at decisions regarding what is best for their child at times of critical illness and (2) the role of parallel planning and advance care plans in that process. This review examines the complexities of decision-making in children with LLCs who are admitted to PCC settings.
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Affiliation(s)
- Peter Sidgwick
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK
| | - James Fraser
- Paediatric Intensive Care Unit, Bristol Children's Hospital, Bristol, UK
| | - Peter-Marc Fortune
- Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Manchester, UK
| | - Renee McCulloch
- Louis Dundas Centre for Children's Palliative Care, Great Ormond Street Hospital, London, UK
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21
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Mitchell S, Spry JL, Hill E, Coad J, Dale J, Plunkett A. Parental experiences of end of life care decision-making for children with life-limiting conditions in the paediatric intensive care unit: a qualitative interview study. BMJ Open 2019; 9:e028548. [PMID: 31072863 PMCID: PMC6528052 DOI: 10.1136/bmjopen-2018-028548] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To provide an in-depth insight into the experience and perceptions of bereaved parents who have experienced end of life care decision-making for children with life-limiting or life-threatening conditions in the paediatric intensive care unit (PICU). DESIGN An in-depth qualitative interview study with a sample of parents of children with life-limiting or life-threatening conditions who had died in PICU within the previous 12 months. A thematic analysis was conducted on the interview transcripts. SETTING A PICU in a large National Health Service (NHS) tertiary children's hospital in the West Midlands, UK. PARTICIPANTS 17 parents of 11 children who had died in the PICU. RESULTS Five interconnected themes were identified related to end of life care decision-making:(1) parents have significant knowledge and experiences that influence the decision-making process.(2) Trusted relationships with healthcare professionals are key to supporting parents making end of life decisions.(3) Verbal and non-verbal communication with healthcare professionals impacts on the family experience.(4) Engaging with end of life care decision-making can be emotionally overwhelming, but becomes possible if parents reach a 'place of acceptance'.(5) Families perceive benefits to receiving end of life care for their child in a PICU. CONCLUSIONS AND IMPLICATIONS The death of a child is an intensely emotional experience for all involved. This study adds to the limited evidence base related to parental experiences of end of life care decision-making and provides findings that have international relevance, particularly related to place of care and introduction of end of life care discussions. The expertise and previous experience of parents is highly relevant and should be acknowledged. End of life care decision-making is a complex and nuanced process; the information needs and preferences of each family are individual and need to be understood by the professionals involved in their care.
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Affiliation(s)
- Sarah Mitchell
- Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Jenna L Spry
- Paediatric Intensive Care Unit, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Emma Hill
- Paediatric Intensive Care Unit, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Jane Coad
- School of Health Sciences, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Adrian Plunkett
- Paediatric Intensive Care Unit, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, Birmingham, UK
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22
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Redshaw M, Henderson J. Mothers' experience of maternity and neonatal care when babies die: A quantitative study. PLoS One 2018; 13:e0208134. [PMID: 30517175 PMCID: PMC6281265 DOI: 10.1371/journal.pone.0208134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/12/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The death of a newborn baby is devastating. While clinical issues may be a primary concern, interpersonal aspects can impact significantly. Mothers in this situation are not easy to access for research and little quantitative evidence is available. In this study we aimed to describe their experience of care, emphasising associations with infant gestational age. METHODS Secondary analysis of population-based survey data collected through the Office for National Statistics following neonatal death in England in 2012-13. Women were asked about clinical events and care during pregnancy, labour and birth, when the baby died, postnatally and in the neonatal unit. RESULTS 249 mothers returned completed questionnaires (30% response rate), 50% of births were at 28 weeks' gestation or less and 66% had babies admitted for neonatal care. 24% of women were left alone and worried during labour and 18% after birth. Only 49% felt sufficiently involved in decision-making at this time. Postnatally only 53% were cared for away from other mothers and babies, 47% could not have their partner stay with them, and 55% were not located close to their baby. Mothers of term babies were significantly less likely to report confidence in staff, feeling listened to and having concerns taken seriously during labour, and postnatally many felt insufficiently informed about their baby's condition, and that neonatal staff were not always aware of parental needs. However, most mothers (84%) were satisfied with neonatal care. CONCLUSIONS There is room for improvement if women whose babies die in the neonatal period are to receive the care and support they need. Women who have a baby admitted to a neonatal unit should be cared for nearby, with room for their partner and with greater involvement in decision-making, particularly where withdrawal of life support is considered.
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Affiliation(s)
- Maggie Redshaw
- Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
- * E-mail:
| | - Jane Henderson
- Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom
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23
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Supporting Parent Caregivers of Children with Life-Limiting Illness. CHILDREN-BASEL 2018; 5:children5070085. [PMID: 29949926 PMCID: PMC6069074 DOI: 10.3390/children5070085] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/20/2018] [Indexed: 11/17/2022]
Abstract
The well-being of parents is essential to the well-being of children with life-limiting illness. Parents are vulnerable to a range of negative financial, physical, and psychosocial issues due to caregiving tasks and other stressors related to the illness of their child. Pediatric palliative care practitioners provide good care to children by supporting their parents in decision-making and difficult conversations, by managing pain and other symptoms in the ill child, and by addressing parent and family needs for care coordination, respite, bereavement, and social and emotional support. No matter the design or setting of a pediatric palliative care team, practitioners can seek to provide for parent needs by referral or intervention by the care team.
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24
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Marsac ML, Kindler C, Weiss D, Ragsdale L. Let's Talk About It: Supporting Family Communication during End-of-Life Care of Pediatric Patients. J Palliat Med 2018; 21:862-878. [PMID: 29775556 DOI: 10.1089/jpm.2017.0307] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Communication is key in optimizing medical care when a child is approaching end of life (EOL). Research is yet to establish best practices for how medical teams can guide intrafamily communication (including surviving siblings) when EOL care is underway or anticipated for a pediatric patient. While recommendations regarding how medical teams can facilitate communication between the medical team and the family exist, various barriers may prevent the implementation of these recommendations. OBJECTIVE This review aims to provide a summary of research-to-date on family and medical provider perceptions of communication during pediatric EOL care. DESIGN Systematic review. RESULTS Findings from a review of 65 studies suggest that when a child enters EOL care, many parents try to protect their child and/or themselves by avoiding discussions about death. Despite current recommendations, medical teams often refrain from discussing EOL care with pediatric patients until death is imminent for a variety of reasons (e.g., family factors and discomfort with EOL conversations). Parents consistently report a need for honest complete information, delivered with sensitivity. Pediatric patients often report a preference to be informed of their prognosis, and siblings express a desire to be involved in EOL discussions. CONCLUSIONS Families may benefit from enhanced communication around EOL planning, both within the family and between the family and medical team. Future research should investigate a potential role for medical teams in supporting intrafamily communication about EOL challenges and should examine how communication between medical teams and families can be facilitated as EOL approaches.
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Affiliation(s)
- Meghan L Marsac
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky.,2 College of Medicine, University of Kentucky , Lexington, Kentucky
| | - Christine Kindler
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky
| | - Danielle Weiss
- 3 Department of Pediatrics, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Lindsay Ragsdale
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky.,2 College of Medicine, University of Kentucky , Lexington, Kentucky
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25
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Ekberg S, Bradford NK, Herbert A, Danby S, Yates P. Healthcare Users' Experiences of Communicating with Healthcare Professionals About Children Who Have Life-Limiting Conditions: A Qualitative Systematic Review. J Palliat Med 2018; 21:1518-1528. [PMID: 29762072 DOI: 10.1089/jpm.2017.0422] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Globally, an estimated eight million children could benefit from palliative care each year. Effective communication about children with life-limiting conditions is well recognized as a critical component of high-quality pediatric palliative care. OBJECTIVE To synthesize existing qualitative research exploring healthcare users' experiences of communicating with healthcare professionals about children with life-limiting conditions. DESIGN The results of a systematic literature search were screened independently by two reviewers. Raw data and analytic claims were extracted from included studies and were synthesized using thematic analysis methods for systematic reviews. DATA SOURCES MEDLINE, PubMed, CINAHL, Embase, PsycINFO, Scopus, Web of Science, ProQuest, and ScienceDirect were searched for articles published in English between 1990 and May 2017. RESULTS This review included 29 studies conducted across 11 countries and involving at least 979 healthcare users (adults [n = 914], patients [n = 25], and siblings [n = 40]). The four domains of communication experience identified through thematic synthesis are: Information, Emotion, Collaboration, and Relationship. Although included studies were from a range of settings and diverse populations, further research is needed to explore whether and how domains of communication experience differ across settings and populations. In particular, further research about children's palliative care experiences is needed. CONCLUSIONS Healthcare users typically value communication with healthcare professionals: that (1) is open and honest, (2) acknowledges emotion, (3) actively involves healthcare users, and (4) occurs within established and trusting relationships.
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Affiliation(s)
- Stuart Ekberg
- 1 Institute of Health and Biomedical Innovation , Queensland University of Technology, Brisbane, Queensland, Australia .,2 School of Psychology and Counselling, Queensland University of Technology , Queensland, Australia, Brisbane, Queensland, Australia
| | - Natalie K Bradford
- 3 Children's Health Queensland Hospital and Health Service , Brisbane, Queensland, Australia
| | - Anthony Herbert
- 3 Children's Health Queensland Hospital and Health Service , Brisbane, Queensland, Australia .,4 Children's Health Queensland Clinical Unit, Faculty of Medicine, University of Queensland , Brisbane, Queensland, Australia
| | - Susan Danby
- 5 School of Early Childhood and Inclusive Education , Queensland University of Technology, Brisbane, Queensland, Australia
| | - Patsy Yates
- 1 Institute of Health and Biomedical Innovation , Queensland University of Technology, Brisbane, Queensland, Australia .,6 School of Nursing, Queensland University of Technology , Brisbane, Queensland, Australia
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Abstract
OBJECTIVES Typically pediatric end-of-life decision-making studies have examined the decision-making process, factors, and doctors' and parents' roles. Less attention has focussed on what happens after an end-of-life decision is made; that is, decision enactment and its outcome. This study explored the views and experiences of bereaved parents in end-of-life decision-making for their child. Findings reported relate to parents' experiences of acting on their decision. It is argued that this is one significant stage of the decision-making process. METHODS A qualitative methodology was used. Semi-structured interviews were conducted with bereaved parents, who had discussed end-of-life decisions for their child who had a life-limiting condition and who had died. Data were thematically analysed. RESULTS Twenty-five bereaved parents participated. Findings indicate that, despite differences in context, including the child's condition and age, end-of-life decision-making did not end when an end-of-life decision was made. Enacting the decision was the next stage in a process. Time intervals between stages and enactment pathways varied, but the enactment was always distinguishable as a separate stage. Decision enactment involved making further decisions - parents needed to discern the appropriate time to implement their decision to withdraw or withhold life-sustaining medical treatment. Unexpected events, including other people's actions, impacted on parents enacting their decision in the way they had planned. Several parents had to re-implement decisions when their child recovered from serious health issues without medical intervention. Significance of results A novel, critical finding was that parents experienced end-of-life decision-making as a sequence of interconnected stages, the final stage being enactment. The enactment stage involved further decision-making. End-of-life decision-making is better understood as a process rather than a discrete once-off event. The enactment stage has particular emotional and practical implications for parents. Greater understanding of this stage can improve clinician's support for parents as they care for their child.
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Birchley G, Gooberman-Hill R, Deans Z, Fraser J, Huxtable R. 'Best interests' in paediatric intensive care: an empirical ethics study. Arch Dis Child 2017; 102:930-935. [PMID: 28408466 PMCID: PMC5739819 DOI: 10.1136/archdischild-2016-312076] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/30/2017] [Accepted: 03/08/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In English paediatric practice, English law requires that parents and clinicians agree the 'best interests' of children and, if this is not possible, that the courts decide. Court intervention is rare and the concept of best interests is ambiguous. We report qualitative research exploring how the best interests standard operates in practice, particularly with decisions related to planned non-treatment. We discuss results in the light of accounts of best interests in the medical ethics literature. DESIGN We conducted 39 qualitative interviews, exploring decision making in the paediatric intensive care unit, with doctors, nurses, clinical ethics committee members and parents whose children had a range of health outcomes. Interviews were audio-recorded and analysed thematically. RESULTS Parents and clinicians indicated differences in their approaches to deciding the child's best interests. These were reconciled when parents responded positively to clinicians' efforts to help parents agree with the clinicians' view of the child's best interests. Notably, protracted disagreements about a child's best interests in non-treatment decisions were resolved when parents' views were affected by witnessing their child's physical deterioration. Negotiation was the norm and clinicians believed avoiding the courts was desirable. CONCLUSIONS Sensitivity to the long-term interests of parents of children with life-limiting conditions is defensible but must be exercised proportionately. Current approaches emphasise negotiation but offer few alternatives when decisions are at an impasse. In such situations, the instrumental role played by a child's deterioration and avoidance of the courts risks giving insufficient weight to the child's interests. New approaches to decision making are needed.
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Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | | | - Zuzana Deans
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - James Fraser
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
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Popejoy E, Pollock K, Almack K, Manning JC, Johnston B. Decision-making and future planning for children with life-limiting conditions: a qualitative systematic review and thematic synthesis. Child Care Health Dev 2017; 43:627-644. [PMID: 28402040 DOI: 10.1111/cch.12461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 02/24/2017] [Accepted: 03/13/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND In the last decade, the number of children with life-limiting and life-threatening conditions in England has almost doubled, and it is estimated that worldwide, there are 1.2 million children with palliative care needs. Families and professionals caring for children with life-limiting conditions are likely to face a number of difficult treatment decisions and develop plans for future care over the course of the child's life, but little is known about the process by which these decisions and plans are made. METHODS The purpose of this review is to synthesize findings from qualitative research that has investigated decision-making and future planning for children with life-limiting conditions. A systematic search of six online databases was conducted and identified 887 papers for review; five papers were selected for inclusion, using predefined criteria. Reference list searching and contacting authors identified a further four papers for inclusion. RESULTS Results sections of the papers were coded and synthesized into themes. Nineteen descriptive themes were identified, and these were further synthesized into four analytical themes. Analytical themes were 'decision factors', 'family factors', 'relational factors' and 'system factors'. CONCLUSIONS Review findings indicate that decision-making and future planning is difficult and needs to be individualized for each family. However, deficits in understanding the dynamic, relational and contextual aspects of decision-making remain and require further research.
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Affiliation(s)
- E Popejoy
- University of Nottingham School of Health Sciences, Nottingham, UK
| | - K Pollock
- Nottingham Children's Hospital, Nottingham, UK
| | - K Almack
- University of Nottingham School of Health Sciences, Nottingham, UK
| | - J C Manning
- University of Nottingham School of Health Sciences, Nottingham, UK
| | - B Johnston
- University of Glasgow School of Medicine, Glasgow, UK
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Professional Responsibility, Consensus, and Conflict: A Survey of Physician Decisions for the Chronically Critically Ill in Neonatal and Pediatric Intensive Care Units. Pediatr Crit Care Med 2017; 18:e415-e422. [PMID: 28658198 DOI: 10.1097/pcc.0000000000001247] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe neonatologist and pediatric intensivist attitudes and practices relevant to high-stakes decisions for children with chronic critical illness, with particular attention to physician perception of professional duty to seek treatment team consensus and to disclose team conflict. DESIGN Self-administered online survey. SETTING U.S. neonatal ICUs and PICUs. SUBJECTS Neonatologists and pediatric intensivists. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We received 652 responses (333 neonatologists, denominator unknown; 319 of 1,290 pediatric intensivists). When asked about guiding a decision for tracheostomy in a chronically critically ill infant, only 41.7% of physicians indicated professional responsibility to seek a consensus decision, but 73.3% reported, in practice, that they would seek consensus and make a consensus-based recommendation; the second most common practice (15.5%) was to defer to families without making recommendations. When presented with conflict among the treatment team, 63% of physicians indicated a responsibility to be transparent about the decision-making process and reported matching practices. Neonatologists more frequently reported a responsibility to give decision making fully over to families; intensivists were more likely to seek out consensus among the treatment team. CONCLUSIONS ICU physicians do not agree about their responsibilities when approaching difficult decisions for chronically critically ill children. Although most physicians feel a professional responsibility to provide personal recommendations or defer to families, most physicians report offering consensus recommendations. Nearly all physicians embrace a sense of responsibility to disclose disagreement to families. More research is needed to understand physician responsibilities for making recommendations in the care of chronically critically ill children.
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Davies B, Steele R, Krueger G, Albersheim S, Baird J, Bifirie M, Cadell S, Doane G, Garga D, Siden H, Strahlendorf C, Zhao Y. Best Practice in Provider/Parent Interaction. QUALITATIVE HEALTH RESEARCH 2017; 27:406-420. [PMID: 27557925 DOI: 10.1177/1049732316664712] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In this 3-year prospective grounded theory study in three pediatric settings, we aimed to develop a conceptualization of best practice health care providers (BPHCPs) in interaction with parents of children with complex, chronic, life-threatening conditions. Analysis of semistructured interviews with 34 parents and 80 health care professionals (HCPs) and 88 observation periods of HCP/parent interactions indicated that BPHCPs shared a broad worldview; values of equity, family-centered care, and integrity; and a commitment to authentic engagement. BPHCPs engaged in direct care activities, in connecting behaviors, and in exquisitely attuning to particularities of the situation in the moment, resulting in positive outcomes for parents and HCPs. By focusing on what HCPs do well, findings showed that not only is it possible for HCPs to practice in this way, but those who do so are also recognized as being the best at what they do. We provide recommendations for practice and initial and ongoing professional education.
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Affiliation(s)
- Betty Davies
- 1 University of Victoria, Victoria, British Columbia, Canada
| | | | - Guenther Krueger
- 3 Retired NVivo Computer Software Consultant, Burnaby, British Columbia, Canada
| | - Susan Albersheim
- 4 Children's & Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | | | - Michelle Bifirie
- 6 University of British Columbia, Vancouver, British Columbia, Canada
| | - Susan Cadell
- 7 University of Waterloo, Waterloo, Ontario, Canada
| | - Gweneth Doane
- 1 University of Victoria, Victoria, British Columbia, Canada
| | - Deepshikha Garga
- 4 Children's & Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Harold Siden
- 4 Children's & Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Caron Strahlendorf
- 4 Children's & Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
| | - Yuan Zhao
- 3 Retired NVivo Computer Software Consultant, Burnaby, British Columbia, Canada
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31
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Lindley LC, Newnam KM. Hospice Use for Infants With Life-Threatening Health Conditions, 2007 to 2010. J Pediatr Health Care 2017; 31:96-103. [PMID: 27245660 PMCID: PMC5125910 DOI: 10.1016/j.pedhc.2016.04.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 04/11/2016] [Accepted: 04/22/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Infant deaths account for a majority of all pediatric deaths. However, little is known about the factors that influence parents to use hospice care for their infant with a life-threatening health condition. METHODS Data were used from 2007 to 2010 California Medicaid claims files (N = 207). Analyses included logistic and negative binomial multivariate regression models. RESULTS More than 15% of infants enrolled in hospice care for an average of 5 days. Infant girls and infants with congenital anomalies were more likely to enroll in hospice care and to have longer stays. However, cardiovascular and respiratory conditions were negatively related to hospice enrollment and hospice length of stay. CONCLUSIONS This study provides insights for nurses and other clinicians who care for infants and their families at end of life and suggests that nurses can assist families in identifying infant hospice providers who may help families understand their options for end-of-life care.
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Zaal-Schuller IH, Willems DL, Ewals FVPM, van Goudoever JB, de Vos MA. How parents and physicians experience end-of-life decision-making for children with profound intellectual and multiple disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 59:283-293. [PMID: 27665411 DOI: 10.1016/j.ridd.2016.09.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/28/2016] [Accepted: 09/15/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND End-of-life decisions (EoLD) often concern children with profound intellectual and multiple disabilities (PIMD). Yet, little is known about how parents and physicians discuss and make these decisions. AIMS The objective of this research was to investigate the experiences of the parents and the involved physician during the end-of-life decision-making (EoLDM) process for children with PIMD. METHODS In a retrospective, qualitative study, we conducted semi-structured interviews with the physicians and parents of 14 children with PIMD for whom an EoLD was made within the past two years. RESULTS A long-lasting relationship appeared to facilitate the EoLDM process, although previous negative healthcare encounters could also lead to distrust. Parents and physicians encountered disagreements during the EoLDM process, but these disagreements could also improve the decision-making process. Most parents, as well as most physicians, considered the parents to be the experts on their child. In making an EoLD, both parents and physicians preferred a shared decision-making approach, although they differed in what they actually meant by this concept. CONCLUSION The EoLDM process for children with PIMD can be improved if physicians are more aware of the specific situation and of the roles and expectations of the parents of children with PIMD.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital - Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Beecham E, Oostendorp L, Crocker J, Kelly P, Dinsdale A, Hemsley J, Russell J, Jones L, Bluebond-Langner M. Keeping all options open: Parents' approaches to advance care planning. Health Expect 2016; 20:675-684. [PMID: 27670148 PMCID: PMC5512998 DOI: 10.1111/hex.12500] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Early engagement in advance care planning (ACP) is seen as fundamental for ensuring the highest standard of care for children and young people with a life-limiting condition (LLC). However, most families have little knowledge or experience of ACP. OBJECTIVE To investigate how parents of children and young people with LLCs approach and experience ACP. METHODS Open-ended, semi-structured interviews were conducted with parents of 18 children; nine children who were currently receiving palliative care services, and nine children who had received palliative care and died. Verbatim transcripts of audiotaped interviews were analysed following principles of grounded theory while acknowledging the use of deductive strategies, taking account of both the child's condition, and the timing and nature of decisions made. RESULTS Parents reported having discussions and making decisions about the place of care, place of death and the limitation of treatment. Most decisions were made relatively late in the illness and by parents who wished to keep their options open. Parents reported different levels of involvement in a range of decisions; many wished to be involved in decision making but did not always feel able to do so. DISCUSSION This study highlights that parents' approaches to decision making vary by the type of decision required. Their views may change over time, and it is important to allow them to keep their options open. We recommend that clinicians have regular discussions over the course of the illness in an effort to understand parents' approaches to particular decisions rather than to drive to closure prematurely.
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Affiliation(s)
- Emma Beecham
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, University College London, London, UK.,Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Linda Oostendorp
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, University College London, London, UK
| | - Joanna Crocker
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, University College London, London, UK
| | - Paula Kelly
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, University College London, London, UK
| | - Andrew Dinsdale
- Louis Dundas Centre for Children's Palliative Care, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - June Hemsley
- Louis Dundas Centre for Children's Palliative Care, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Jessica Russell
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, University College London, London, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, University College London, London, UK.,Department of Sociology, Anthropology and Criminal Justice, Rutgers University, Camden, NJ, USA
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Zaal-Schuller IH, de Vos MA, Ewals FVPM, van Goudoever JB, Willems DL. End-of-life decision-making for children with severe developmental disabilities: The parental perspective. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 49-50:235-246. [PMID: 26741261 DOI: 10.1016/j.ridd.2015.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 11/28/2015] [Accepted: 12/08/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND AIMS The objectives of this integrative review were to understand how parents of children with severe developmental disorders experience their involvement in end-of-life decision-making, how they prefer to be involved and what factors influence their decisions. METHODS AND PROCEDURES We searched MEDLINE, EMBASE, CINAHL and PsycINFO. The search was limited to articles in English or Dutch published between January 2004 and August 2014. We included qualitative and quantitative original studies that directly investigated the experiences of parents of children aged 0-18 years with severe developmental disorders for whom an end-of-life decision had been considered or made. OUTCOMES AND RESULTS We identified nine studies that met all inclusion criteria. Reportedly, parental involvement in end-of-life decision-making varied widely, ranging from having no involvement to being the sole decision-maker. Most parents preferred to actively share in the decision-making process regardless of their child's specific diagnosis or comorbidity. The main factors that influenced parents in their decision-making were: their strong urge to advocate for their child's best interests and to make the best (possible) decision. In addition, parents felt influenced by their child's visible suffering, remaining quality of life and the will they perceived in their child to survive. CONCLUSIONS AND IMPLICATIONS Most parents of children with severe developmental disorders wish to actively share in the end-of-life decision-making process. An important emerging factor in this process is the parents' feeling that they have to stand up for their child's interests in conversations with the medical team.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital-Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Clément de Cléty S, Friedel M, Verhagen AAE, Lantos JD, Carter BS. Please Do Whatever It Takes to End Our Daughter's Suffering! Pediatrics 2016; 137:peds.2015-3812. [PMID: 26644491 DOI: 10.1542/peds.2015-3812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2015] [Indexed: 11/24/2022] Open
Abstract
What is the best way to care for a child with severe neurologic impairment who seems to be dying and is in intractable pain? Can we give sedation as we remove life support? Is it ethically permissible to hasten death? In the United States, 5 states have legalized assisted suicide (although only for competent adults). In Belgium and the Netherlands, euthanasia is legal for children under some circumstances. We present a case in which parents and doctors face difficult decisions about palliative care. Experts from Belgium, the Netherlands, and the United States then discuss how they would respond to such a case.
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Affiliation(s)
| | - Marie Friedel
- Haute Ecole Vinci and Université catholique de Louvain, Brussels, Belgium
| | - A A Eduard Verhagen
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; and
| | - John D Lantos
- Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
| | - Brian S Carter
- Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
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36
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Forbat L, Sayer C, McNamee P, Menson E, Barclay S. Conflict in a paediatric hospital: a prospective mixed-method study. Arch Dis Child 2015; 101:23-7. [PMID: 26553912 PMCID: PMC4770249 DOI: 10.1136/archdischild-2015-308814] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/09/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Conflict in healthcare is a well-recognised but under-examined phenomenon. Little is known about the prevalence and causes of conflict across paediatric specialties. OBJECTIVE To report the frequency and characteristics of conflict in a paediatric hospital. DESIGN AND SETTING An explanatory sequential mixed-method approach was adopted. A bespoke questionnaire recorded frequency, severity, cause and staff involved in conflict prospectively. Data were recorded for the same two 12-week periods in 2013 and 2014, in one UK children's teaching hospital. Data were analysed using descriptive statistics and correlation, the findings of which informed the construction of a semistructured interview schedule. Qualitative interviews were conducted with six key informant healthcare professionals to aid data interpretation; interviews were analysed thematically. RESULTS 136 individual episodes of conflict were reported. The three most common causes were 'communication breakdown', 'disagreements about treatment' and 'unrealistic expectations'. Over 448 h of healthcare professional time was taken up by these conflicts; most often staff nurses, consultants, doctors in training and matrons. The mean severity rating was 4.9 out of 10. Qualitative interviews revealed consensus regarding whether conflicts were ranked as low, medium or high severity, and explanations regarding why neurology recorded the highest number of conflicts in the observed period. CONCLUSIONS Conflict is prevalent across paediatric specialties, and particularly in neurology, general paediatrics and neonatology. Considerable staff time is taken in managing conflict, indicating a need to focus resources on supporting staff to resolve conflict, notably managing communication breakdown.
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Affiliation(s)
- Liz Forbat
- School of Health Sciences, Australian Catholic University and Calvary Health Care, Canberra, Australian Capital Territory, Australia
| | | | - Phillip McNamee
- School of Health Sciences, University of Stirling, Stirling, UK
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Mitchell S, Dale J. Advance Care Planning in palliative care: a qualitative investigation into the perspective of Paediatric Intensive Care Unit staff. Palliat Med 2015; 29:371-9. [PMID: 25721360 DOI: 10.1177/0269216315573000] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The majority of children and young people who die in the United Kingdom have pre-existing life-limiting illness. Currently, most such deaths occur in hospital, most frequently within the intensive care environment. AIM To explore the experiences of senior medical and nursing staff regarding the challenges associated with Advance Care Planning in relation to children and young people with life-limiting illnesses in the Paediatric Intensive Care Unit environment and opportunities for improvement. DESIGN Qualitative one-to-one, semi-structured interviews were conducted with Paediatric Intensive Care Unit consultants and senior nurses, to gain rich, contextual data. Thematic content analysis was carried out. SETTING/PARTICIPANTS UK tertiary referral centre Paediatric Intensive Care Unit. Eight Paediatric Intensive Care Unit consultants and six senior nurses participated. FINDINGS Four main themes emerged: recognition of an illness as 'life-limiting'; Advance Care Planning as a multi-disciplinary, structured process; the value of Advance Care Planning and adverse consequences of inadequate Advance Care Planning. Potential benefits of Advance Care Planning include providing the opportunity to make decisions regarding end-of-life care in a timely fashion and in partnership with patients, where possible, and their families. Barriers to the process include the recognition of the life-limiting nature of an illness and gaining consensus of medical opinion. Organisational improvements towards earlier recognition of life-limiting illness and subsequent Advance Care Planning were recommended, including education and training, as well as the need for wider societal debate. CONCLUSIONS Advance Care Planning for children and young people with life-limiting conditions has the potential to improve care for patients and their families, providing the opportunity to make decisions based on clear information at an appropriate time, and avoid potentially harmful intensive clinical interventions at the end of life.
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Affiliation(s)
- Sarah Mitchell
- Birmingham Children's Hospital, Birmingham, UK Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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38
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Abstract
One of the many difficult moments for families of children with life-limiting illnesses is to make the decision to access pediatric hospice care. Although determinants that influence families' decisions to access pediatric hospice care have been recently identified, the relationship between these determinants and access to pediatric hospice care have not been explicated or grounded in accepted healthcare theories or models. Using the Andersen Behavioral Healthcare Utilization Model, this article presents a conceptual model describing the determinants of hospice access. Predisposing (demographic; social support; and knowledge, beliefs, and values), enabling (family and community resources) and need (perceived and evaluated needs) factors were identified through the use of hospice literature. The relationships among these factors are described and implications of the model for future study and practice are discussed.
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39
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de Vos MA, Bos AP, Plötz FB, van Heerde M, de Graaff BM, Tates K, Truog RD, Willems DL. Talking with parents about end-of-life decisions for their children. Pediatrics 2015; 135:e465-76. [PMID: 25560442 DOI: 10.1542/peds.2014-1903] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Retrospective studies show that most parents prefer to share in decisions to forgo life-sustaining treatment (LST) from their children. We do not yet know how physicians and parents communicate about these decisions and to what extent parents share in the decision-making process. METHODS We conducted a prospective exploratory study in 2 Dutch University Medical Centers. RESULTS Overall, 27 physicians participated, along with 37 parents of 19 children for whom a decision to withhold or withdraw LST was being considered. Forty-seven conversations were audio recorded, ranging from 1 to 8 meetings per patient. By means of a coding instrument we quantitatively and qualitatively analyzed physicians' and parents' communicative behaviors. On average, physicians spoke 67% of the time, parents 30%, and nurses 3%. All physicians focused primarily on providing medical information, explaining their preferred course of action, and informing parents about the decision being reached by the team. Only in 2 cases were parents asked to share in the decision-making. Despite their intense emotions, most parents made great effort to actively participate in the conversation. They did this by asking for clarifications, offering their preferences, and reacting to the decision being proposed (mostly by expressing their assent). In the few cases where parents strongly preferred LST to be continued, the physicians either gave parents more time or revised the decision. CONCLUSIONS We conclude that parents are able to handle a more active role than they are currently being given. Parents' greatest concern is that their child might suffer.
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Affiliation(s)
- Mirjam A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands;
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Frans B Plötz
- Department of Paediatrics, Tergooiziekenhuizen, Hilversum, Netherlands
| | - Marc van Heerde
- Department of Paediatric Intensive Care, VU University Medical Centre, Amsterdam, Netherlands
| | - Bert M de Graaff
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Kiek Tates
- Department of Communication and Information Studies, Tilburg University, Tilburg, Netherlands; and
| | - Robert D Truog
- Division of Critical Care Medicine, Boston Children's Hospital; Division of Medical Ethics, Harvard Medical School, Boston, Massachusetts
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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Isaacs D. Ethics of paediatric end-of-life decision making and consent for publication. JOURNAL OF MEDICAL ETHICS 2015; 41:201-202. [PMID: 24958335 DOI: 10.1136/medethics-2014-102235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- David Isaacs
- Clinical Ethics Children's Hospital at Westmead, Sydney, New South Wales, Australia Discipline of Child Health, University of Sydney, Sydney, New South Wales, Australia
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Friedel M. Does the Belgian law legalising euthanasia for minors really address the needs of life-limited children? Int J Palliat Nurs 2014; 20:265-7. [PMID: 25040860 DOI: 10.12968/ijpn.2014.20.6.265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marie Friedel
- Paediatric Nurse and Lecturer in Paediatric Palliative Care, Haute Ecole Léonard De Vinci, Promenade de l'Alma 50, 1200 Woluwe-Saint-Lambert, Brussels, Belgium
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