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Ting J, Songer K, Bailey V, Rotman C, Lipsitz S, Rosenberg AR, Delgado-Corcoran C, Moynihan KM. Impact of Subspecialty Pediatric Palliative Care on Children with Heart Disease; A Systematic Review and Meta-analysis. Pediatr Cardiol 2024:10.1007/s00246-024-03535-4. [PMID: 38907871 DOI: 10.1007/s00246-024-03535-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/23/2024] [Indexed: 06/24/2024]
Abstract
While many experts in pediatric cardiology have emphasized the importance of palliative care involvement, very few studies have assessed the influence of specialty pediatric palliative care (SPPC) involvement for children with heart disease. We conducted a systematic review using keywords related to palliative care, quality of life and care-satisfaction, and heart disease. We searched PubMed, EMBASE, CINAHL, CENTRAL and Web of Science in December 2023. Screening, data extraction and methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Pairs of trained reviewers independently evaluated each article. All full texts excluded from the review were hand-screened for eligible references including systematic reviews in general pediatric populations. Two reviewers independently extracted: (1) study design; (2) methodology; (2) setting; (3) population; (4) intervention/exposure and control definition; (5) outcome measures; and (6) results. Of 4059 studies screened, 9 met inclusion criteria including two with overlapping patient data. Study designs were heterogenous, including only one randomized control and two historical control trials with SPPC as a prospective intervention. Overall, there was moderate to high risk of bias. Seven were single centers studies. In combined estimates, patients who received SPPC were more likely to have advance care planning documented (RR 2.7, [95%CI 1.6, 4.7], p < 0.001) and resuscitation limits (RR 4.0, [2.0, 8.1], p < 0.001), while half as likely to have active resuscitation at end-of-life ([0.3, 0.9], p = 0.032). For parental stress, receipt of SPPC improved scores by almost half a standard deviation (RR 0.48, 95%CI 0.10, 0.86) more than controls. Ultimately, we identified a paucity of high-quality data studying the influence of SPPC; however, findings correlate with literature in other pediatric populations. Findings suggest benefits of SPPC integration for patients with heart disease and their families.
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Affiliation(s)
- James Ting
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Kathryn Songer
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Valerie Bailey
- Department of Cardiology, Boston Children's Hospital, MS BCH3215, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Chloe Rotman
- Medical Library, Boston Children's Hospital, Boston, MA, USA
| | - Stuart Lipsitz
- Department of General Internal Medicine and Primary Care, Center for Patient Safety, Research, and Practice, Brigham and Women's Hospital, Boston, MA, USA
| | - Abby R Rosenberg
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | | | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, MS BCH3215, 300 Longwood Ave, Boston, MA, 02115, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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Guttmann KF, Puoplo N, Richter F, Weintraub AS. Trends in length of stay for Neonatal Intensive Care Unit patients who die before hospital discharge. Am J Perinatol 2024; 41:700-705. [PMID: 34861703 DOI: 10.1055/a-1712-5313] [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] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objectives of this study were to establish days between birth and death for neonates over a 14-year period, determine if days between birth and death have changed over time across gestational age cohorts, and identify diagnoses which may put infants at high risk of prolonged hospitalization leading to death. STUDY DESIGN This was a single-site, retrospective chart review of inborn infants who died prior to hospital discharge. RESULTS Two hundred and thirty-nine patients born between 1/1/2006 and 12/31/2020 met inclusion criteria. Days until death ranged from 0 to 300 with a median of 6 days (interquartile range = 23). Median days until death increased over time, with a statistically significant increase between epoch 1 and epoch 2 (p = 0.016) but not between epoch 2 and epoch 3 (p = 0.618). Extremely premature infants died earlier than more mature infants (p < 0.001). In addition, infants with complex congenital heart disease or a gastrointestinal (GI) catastrophe died later (p < 0.001 and p < 0.001, respectively) than newborns without cardiac or GI issues. CONCLUSION Our findings demonstrate an increase in time to death for newborns who did not survive to hospital discharge over a 14-year period. This trend suggests that the dynamics informing Meadows' assertion that "doomed infants die early" may be shifting, with some seriously ill infants who die before hospital discharge surviving longer than previously described. More research is needed to understand how best to care for babies who will not survive to discharge and to explore when supports such as palliative care consultation may be beneficial. KEY POINTS As per W. Meadow, "Doomed infants die early" · Pre-death length of stay varies with diagnosis.. · Some seriously ill infants who die before hospital discharge are no longer dying early.. · These infants and families may need supports..
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Affiliation(s)
- Katherine F Guttmann
- Division of Newborn Medicine, Department of Pediatrics, the Icahn School of Medicine at Mount Sinai, New York
| | - Nicholas Puoplo
- Department of Pediatrics, the Icahn School of Medicine at Mount Sinai, New York
| | - Felix Richter
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York
| | - Andrea S Weintraub
- Division of Newborn Medicine, Department of Pediatrics, the Icahn School of Medicine at Mount Sinai, New York
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Taub S, Macauley R. Early and often: Promoting early integration of pediatric palliative care for seriously ill children with cancer. Curr Probl Cancer 2023; 47:101023. [PMID: 37891032 DOI: 10.1016/j.currproblcancer.2023.101023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023]
Abstract
Pediatric palliative care, despite substantial overlap with its adult counterpart, is also distinct in some ways. Serious illness and comorbidities are less common in children, for whom there is a stronger presumption toward aggressive treatment. This, along with impressive cure rates for pediatric cancer, can help explain why children typically survive for a longer period of time following initial palliative care consultation. Though many of the studies demonstrating benefit of integration of palliative care early in the course of the disease for seriously ill patients rather than near or at end-of-life were conducted in adults, similar findings have been documented for children with serious illness. Several barriers to early integration exist, however, including misperceptions that palliative care constitutes "giving up" and concerns about potential role confusion with the primary team. By directly addressing these misperceptions and challenges, it is possible for palliative care and oncology to work in constructive partnerships that will benefit children with cancer and their families.
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Affiliation(s)
- Sara Taub
- Department of Pediatrics, Oregon Health and Science University, Portland, OR.
| | - Robert Macauley
- Department of Pediatrics, Oregon Health and Science University, Portland, OR
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House TR, Wightman A, Smith J, Schwarze M, Bradford MC, Rosenberg AR. Palliative Care Training in Pediatric Nephrology Fellowship: A Cross-Sectional Survey. KIDNEY360 2023; 4:1437-1444. [PMID: 37531201 PMCID: PMC10615382 DOI: 10.34067/kid.0000000000000233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/03/2023] [Accepted: 07/25/2023] [Indexed: 08/03/2023]
Abstract
Key Points Pediatric nephrology fellows have limited primary palliative exposure and opportunities to develop and refine primary palliative care (PC) skills. While experiential practice seems to improve confidence, most fellows have low confidence to provide primary PC. Fellows indicate a need and desire for additional PC training during nephrology fellowship. Background Children with CKD and their families encounter significant burdens. Integrating primary palliative care (PC), holistic care provided by nephrologists focused on enhancing quality of life through symptom management, stress relief, and high-quality serious illness communication, provides an opportunity to promote flourishing. Incorporation of primary PC education in training is therefore recommended. Yet, adult nephrology fellows report inadequate preparation to deliver primary PC. Similar experience of pediatric nephrology fellows is unknown. We sought to describe pediatric nephrology fellows' experience in providing primary PC and PC exposure during training. Methods We administered a cross-sectional web-based survey to pediatric nephrology fellows associated with the American Society of Pediatric Nephrology listserv in May 2021. The survey was adapted from a previously validated instrument and pretested by stakeholder nephrologists and subspecialty PC physicians; queries included institutional and personal PC experience, training, and confidence in primary PC delivery. Data were summarized descriptively. Results Response rate was 32% (32/101). Respondents were 81% female and 50% White; 87% practiced in an urban setting. Only one fellow (3%) completed a PC rotation during fellowship, and 15 respondents (48%) completed a rotation in medical school or residency. Fellows reported substantially more practice conducting kidney biopsies than family meetings; 68% of fellows had performed >10 kidney biopsies, and 3% of fellows had led >10 family meetings. Confidence in navigating challenging communication, addressing psychological distress, or managing physical symptoms associated with CKD was generally low. Fellows with greater exposure to family meetings reported more confidence navigating challenging communication. Fellows endorsed a need for additional training; 97% indicated that training should happen during fellowship. Conclusions Few pediatric nephrology fellows receive PC education or exposure during training, resulting in low rates of knowledge and confidence in primary PC delivery. Fellows indicate a need and desire for improved PC training.
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Affiliation(s)
- Taylor R. House
- Department of Pediatrics, University of Wisconsin Madison, School of Medicine and Public Health, Madison, Wisconsin
| | - Aaron Wightman
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Jodi Smith
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Margaret Schwarze
- Department of Surgery and Department of Medical History and Bioethics, University of Wisconsin Madison, School of Medicine and Public Health, Madison, Wisconsin
| | - Miranda C. Bradford
- Biostatistics Epidemiology and Analytics in Research Core, Seattle Children's Research Institute, Seattle, Washington
| | - Abby R. Rosenberg
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Boston, Massachusetts
- Boston Children's Hospital, Department of Pediatrics, Pediatric Advanced Care Program, Boston, Massachusetts
- Harvard Medical School, Department of Pediatrics, Division of Hematology-Oncology, Boston, Massachusetts
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Chen SH, Wu ET, Wang CC, Su MY, Chang CH, Chen HL, Lu FL, Cheng SY. Increasing Trend and Effects of Pediatric Palliative Care on Children With Noncancer Diagnoses. J Pain Symptom Manage 2023; 66:230-237.e1. [PMID: 37290731 DOI: 10.1016/j.jpainsymman.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/18/2023] [Accepted: 05/30/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Pediatric palliative care (PPC), especially among noncancer pediatric patients, faces challenges including late referral, limited patient care, and insufficient data for Asian patients. METHODS This retrospective cohort study used the integrative hospital medical database between 2014 and 2018 to analyze the clinical characteristics, diagnoses, and end-of-life care for patients aged less than 20 who had died in our children's hospital, a tertiary referral medical center implementing PPC shared-care. RESULTS In our cohort of 323 children, 240 (74.3%) were noncancer patients who a younger median age at death (5 vs. 122 months, P < 0.001), lower rate of PPC involvement (16.7 vs. 66%, P < 0.001), and fewer survival days after PPC consult compared to cancer patients (3 vs. 11, P = 0.01). Patients not receiving PPC had more ventilator support (OR 9.9, P < 0.001), and less morphine use on their final day of life (OR 0.1, P < 0.001). Also, patients not receiving PPC had more cardiopulmonary resuscitation on the last day of life (OR 15.3, P < 0.001) and died in the ICU (OR 8.8, P < 0.001). There was an increasing trend of noncancer patients receiving PPC between 2014 and 2018 (P < 0.001). CONCLUSIONS High disparities exist between children receiving PPC in cancer versus noncancer patients. The concept of PPC is gradually becoming accepted in noncancer children and is associated with more pain-relief medication and less suffering during end-of-life care.
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Affiliation(s)
- Szu-Han Chen
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - En-Ting Wu
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Chia Wang
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Min-Yu Su
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Division of Pediatric Hematology and Oncology (M.Y.S.), China Medical University Children's Hospital, Taichung, Taiwan
| | - Chin-Hao Chang
- Department of Medical Research (C.H.C.), National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Ling Chen
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department and Graduate Institute of Medical Education and Bioethics (H.L.C.), National Taiwan University College of Medicine, Taipei, Taiwan
| | - Frank Leigh Lu
- Department of Pediatrics (S.H.C., E.T.W., C.C.W., M.Y.S., H.L.C., F.L.L.), National Taiwan University Children's Hospital, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Shao-Yi Cheng
- Department of Family Medicine (S.Y.C.), National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Alotaibi Q, Dighe M. Assessing the Need for Pediatric Palliative Care in the Six Arab Gulf Cooperation Council Countries. Palliat Med Rep 2023; 4:36-40. [PMID: 36910455 PMCID: PMC9994439 DOI: 10.1089/pmr.2022.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 02/18/2023] Open
Abstract
Background Palliative care is an essential element of universal health coverage. However, palliative care services, particularly pediatric palliative care (PPC) services, are still inadequately developed in many countries, not least members of the Gulf Cooperation Council (GCC) (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). Advocating for palliative care services requires data-driven estimates of the number of patients needing these services. Objective To estimate the number of children living with life-threatening illnesses in the GCC countries requiring specialist and/or generalist palliative care service provision. Method Descriptive analysis of published cross-sectional epidemiological data. Subjects were from general and age-specific populations from individual GCC countries. The quantitative data on child population and mortality were collected from 2019 primary and secondary data sources. The need for PPC was estimated using mortality, incidence, and prevalence data from the Institute for Health Metrics and the Global Cancer Observatory. Results Our conservative analysis revealed that just under 22,000 children needed PPC in GCC countries in 2019, a minimum of 17.5 for every 10,000 children. Discussion There is a significant need for PPC services, suggesting that the medical needs of the pediatric population are currently not being fully met. Nationwide PPC services are essential to improve the quality of life of thousands of children in GCC countries by changing policies, professional education, and providing funding to palliative programs. To our best knowledge, this is the first study to highlight the clear and urgent need for the development of PPC services in the GCC countries.
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Affiliation(s)
- Qutaibah Alotaibi
- Pediatric Department, Aladan Hospital, Hadiya, Kuwait
- Address correspondence to: Qutaibah Alotaibi, MD, Pediatric Department, Aladan Hospital, King Faahad Bin Abdul Aziz Road, Hadiya, Al-Alhadi Governorate, Kuwait.
| | - Manjiri Dighe
- Pediatric Department, Aladan Hospital, Hadiya, Kuwait
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7
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Madrigal VN, Feltman DM, Leuthner SR, Kirsch R, Hamilton R, Dokken D, Needle J, Boss R, Lelkes E, Carter B, Macias E, Bhombal S. Bioethics for Neonatal Cardiac Care. Pediatrics 2022; 150:189885. [PMID: 36317974 DOI: 10.1542/peds.2022-056415n] [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] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Clinicians caring for neonates with congenital heart disease encounter challenges with ethical implications in daily practice and must have some basic fluency in ethical principles and practical applications. METHODS Good ethical practice begins with a thorough understanding of the details and narrative of each individual case, examination via classic principles of bioethics, and further framing of that translation into practice. RESULTS We explore some of these issues and expand awareness through the lens of a case presentation beginning with fetal considerations through end-of-life discussions. CONCLUSIONS We include specific sections that bring attention to shared decision-making, research ethics, and outcomes reporting. We review empirical evidence and highlight recommendations.
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Affiliation(s)
- Vanessa N Madrigal
- Department of Pediatrics, Division of Critical Care Medicine and Pediatric Ethics Program, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Dalia M Feltman
- NorthShore University HealthSystem Evanston Hospital, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Steven R Leuthner
- Departments of Pediatrics and Bioethics, Division of Neonatology, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Roxanne Kirsch
- Department of Critical Care, Division Cardiac Critical Care Medicine; Department of Bioethics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rekha Hamilton
- Mednax Inc. Cook Children's Medical Center, Fort Worth, Texas
| | - Deborah Dokken
- Family Leader and Staff Member, Institute for Patient and Family-Centered Care, Bethesda, Maryland
| | - Jennifer Needle
- Department of Pediatrics and the Center for Bioethics, University of Minnesota, Minneapolis, Minnesota
| | - Renee Boss
- Department of Pediatrics, Johns Hopkins School of Medicine and Berman Institute of Bioethics, Baltimore, Maryland
| | - Efrat Lelkes
- Department of Pediatrics, Divisions of Critical Care Medicine and Palliative Medicine, Bioethics, University of California San Francisco, San Francisco, California
| | - Brian Carter
- Departments of Humanities and Pediatrics, Division of Neonatology and Bioethics Center, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Eduardo Macias
- Department of Pediatrics, Division of Pediatric Cardiology. University Hospital, University of Texas, San Antonio, Texas
| | - Shazia Bhombal
- Department of Pediatrics, Lucile Packard Children's Hospital. Stanford, Palo Alto, California
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8
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Congenital Heart Disease: The State-of-the-Art on Its Pharmacological Therapeutics. J Cardiovasc Dev Dis 2022; 9:jcdd9070201. [PMID: 35877563 PMCID: PMC9316572 DOI: 10.3390/jcdd9070201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/17/2022] Open
Abstract
Congenital heart disease is one of the most common causes of death derived from malformations. Historically, its treatment has depended on timely diagnosis and early pharmacological and surgical interventions. Survival rates for patients with this disease have increased, primarily due to advancements in therapeutic choices, but mortality remains high. Since this disease is a time-sensitive pathology, pharmacological interventions are needed to improve clinical outcomes. Therefore, we analyzed the applications, dosage, and side effects of drugs currently used for treating congenital heart disease. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and potassium-sparing diuretics have shown a mortality benefit in most patients. Other therapies, such as endothelin receptor antagonists, phosphodiesterase-5 inhibitors, prostaglandins, and soluble guanylyl cyclase stimulators, have benefited patients with pulmonary artery hypertension. Likewise, the adjunctive symptomatic treatment of these patients has further improved the outcomes, since antiarrhythmics, digoxin, and non-steroidal anti-inflammatory drugs have shown their benefits in these cases. Conclusively, these drugs also carry the risk of troublesome adverse effects, such as electrolyte imbalances and hemodynamic compromise. However, their benefits for survival, symptom improvement, and stabilization outweigh the possible complications from their use. Thus, cases must be assessed individually to accurately identify interventions that would be most beneficial for patients.
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Abstract
BACKGROUND Parents who receive a diagnosis of a severe, life-threatening CHD for their foetus or neonate face a complex and stressful decision between termination, palliative care, or surgery. Understanding how parents make this initial treatment decision is critical for developing interventions to improve counselling for these families. METHODS We conducted focus groups in four academic medical centres across the United States of America with a purposive sample of parents who chose termination, palliative care, or surgery for their foetus or neonate diagnosed with severe CHD. RESULTS Ten focus groups were conducted with 56 parents (Mage = 34 years; 80% female; 89% White). Results were constructed around three domains: decision-making approaches; values and beliefs; and decision-making challenges. Parents discussed varying approaches to making the decision, ranging from relying on their "gut feeling" to desiring statistics and probabilities. Religious and spiritual beliefs often guided the decision to not terminate the pregnancy. Quality of life was an important consideration, including how each option would impact the child (e.g., pain or discomfort, cognitive and physical abilities) and their family (e.g., care for other children, marriage, and career). Parents reported inconsistent communication of options by clinicians and challenges related to time constraints for making a decision and difficulty in processing information when distressed. CONCLUSION This study offers important insights that can be used to design interventions to improve decision support and family-centred care in clinical practice.
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Bergsträsser E, Lukose S, Zimmermann K, Oxenius A. Palliative Care in Children With Advanced Heart Disease in a Tertiary Care Environment: A Mini Review. Front Cardiovasc Med 2022; 9:863031. [PMID: 35463792 PMCID: PMC9023876 DOI: 10.3389/fcvm.2022.863031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Palliative care for children continues to evolve. More recently, this has also been true in the field of pediatric cardiology, particularly for children with advanced heart disease. In these children, similarly to children with cancer, treatment successes are offset by the risks of long-term morbidities, including premature death. This mini review aims to provide an overview of current knowledge on children suffering from advanced heart disease, their medical care during various phases of illness (including the palliative and end-of-life phase), symptom burden, experiences of parents, prognostic understanding of parents and physicians, and current status of the involvement of pediatric palliative care. In conclusion, the suffering of these children at the end of their young lives is pronounced and many parents feel prepared neither for medical problems nor for the child’s death. An effective and mutually trusting partnership between pediatric cardiology and pediatric palliative care would appear to be a prerequisite for the timely involvement of palliative care in further supporting these children and their families.
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Affiliation(s)
- Eva Bergsträsser
- Pediatric Palliative Care, Department of Medicine I, University Children’s Hospital Zurich, Zurich, Switzerland
- *Correspondence: Eva Bergsträsser,
| | - Saumya Lukose
- Pediatric Palliative Care, Department of Medicine I, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Karin Zimmermann
- Pediatric Palliative Care, Department of Medicine I, University Children’s Hospital Zurich, Zurich, Switzerland
- Department Public Health, Nursing Science, University of Basel, Basel, Switzerland
| | - Angela Oxenius
- Pediatric Cardiology, Heart Center, University Children’s Hospital Zurich, Zurich, Switzerland
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11
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Vemuri S, Butler AE, Brown K, Wray J, Bluebond-Langner M. Palliative care for children with complex cardiac conditions: survey results. Arch Dis Child 2022; 107:282-287. [PMID: 34312164 PMCID: PMC8862095 DOI: 10.1136/archdischild-2020-320866] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 07/03/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore perspectives of paediatric cardiac and palliative care professionals on providing palliative care to children with complex cardiac conditions. DESIGN A national survey including closed-ended and open-ended questions as well as clinical scenarios designed to capture referral practices, attitudes towards palliative care, confidence delivering key components of palliative care and perspectives on for whom to provide palliative care. Responses to closed-ended questions and scenarios were analysed using descriptive statistics. Open-ended responses were analysed thematically. PARTICIPANTS Paediatric cardiac and palliative care professionals caring for children with complex cardiac conditions in the UK. RESULTS 177 professionals (91 cardiac care and 86 palliative care) responded. Aspects of advance care planning were the most common reasons for referral to palliative care. Palliative care professionals reported greater confidence than cardiac colleagues with such discussions. Clinicians agreed that children with no further surgical management options, comorbid genetic disorders, antenatal diagnosis of a single ventricle, ventricular device in situ, symptomatic heart failure and those awaiting heart transplantation would benefit from palliative care involvement. CONCLUSIONS Components of palliative care, such as advance care planning, can be provided by cardiac care professionals alongside the disease-directed care of children with complex cardiac conditions. Further research and training are needed to address confidence levels in cardiac care professionals in delivering components of palliative care as well as clarification of professional roles and parent preferences in delivery of family-centred care for children with complex cardiac conditions.
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Affiliation(s)
- Sidharth Vemuri
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia,Louis Dundas Centre for Children's Palliative Care, University College London Great Ormond Street Institute for Child Health, London, UK
| | - Ashleigh E Butler
- Louis Dundas Centre for Children's Palliative Care, University College London Great Ormond Street Institute for Child Health, London, UK,Austin Health Clinical School, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia
| | - Katherine Brown
- Institute of Cardiovascular Science, University College London, London, UK,Heart Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jo Wray
- Institute of Cardiovascular Science, University College London, London, UK,Heart Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK,Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children's Palliative Care, University College London Great Ormond Street Institute for Child Health, London, UK .,Rutgers University, Camden, New Jersey, USA
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12
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Delaney RK, Pinto NM, Ozanne EM, Stark LA, Pershing ML, Thorpe A, Witteman HO, Thokala P, Lambert LM, Hansen LM, Greene TH, Fagerlin A. Study protocol for a randomised clinical trial of a decision aid and values clarification method for parents of a fetus or neonate diagnosed with a life-threatening congenital heart defect. BMJ Open 2021; 11:e055455. [PMID: 34893487 PMCID: PMC8666895 DOI: 10.1136/bmjopen-2021-055455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Parents who receive the diagnosis of a life-threatening, complex heart defect in their fetus or neonate face a difficult choice between pursuing termination (for fetal diagnoses), palliative care or complex surgical interventions. Shared decision making (SDM) is recommended in clinical contexts where there is clinical equipoise. SDM can be facilitated by decision aids. The International Patient Decision Aids Standards collaboration recommends the inclusion of values clarification methods (VCMs), yet little evidence exists concerning the incremental impact of VCMs on patient or surrogate decision making. This protocol describes a randomised clinical trial to evaluate the effect of a decision aid (with and without a VCM) on parental mental health and decision making within a clinical encounter. METHODS AND ANALYSIS Parents who have a fetus or neonate diagnosed with one of six complex congenital heart defects at a single tertiary centre will be recruited. Data collection for the prospective observational control group was conducted September 2018 to December 2020 (N=35) and data collection for two intervention groups is ongoing (began October 2020). At least 100 participants will be randomised 1:1 to two intervention groups (decision aid only vs decision aid with VCM). For the intervention groups, data will be collected at four time points: (1) at diagnosis, (2) postreceipt of decision aid, (3) postdecision and (4) 3 months postdecision. Data collection for the control group was the same, except they did not receive a survey at time 2. Linear mixed effects models will assess differences between study arms in distress (primary outcome), grief and decision quality (secondary outcomes) at 3-month post-treatment decision. ETHICS AND DISSEMINATION This study was approved by the University of Utah Institutional Review Board. Study findings have and will continue to be presented at national conferences and within scientific research journals. TRIAL REGISTRATION NUMBER NCT04437069 (Pre-results).
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Affiliation(s)
- Rebecca K Delaney
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nelangi M Pinto
- Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Elissa M Ozanne
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Louisa A Stark
- Human Genetics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mandy L Pershing
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Alistair Thorpe
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Holly O Witteman
- Family and Emergency Medicine, Laval University, Quebec City, Quebec, Canada
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Linda M Lambert
- Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Lisa M Hansen
- Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Tom H Greene
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Angela Fagerlin
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
- VA HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, UT, USA
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Davis ES, Martinez I, Hurst G, Bhatia S, Johnston EE. Early palliative care is associated with less intense care in children dying with cancer in Alabama: A retrospective, single-site study. Cancer 2021; 128:391-400. [PMID: 34614197 DOI: 10.1002/cncr.33935] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 08/11/2021] [Accepted: 08/30/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Regional studies show that children with cancer receive medically intense end-of-life (EOL) care, but EOL care patterns, including palliative care utilization in Alabama, remain unknown. METHODS This was a retrospective study of 233 children (0-19 years) who received cancer-directed therapy at Children's of Alabama and died from 2010 through 2019. Rates and disparities in palliative care utilization and the association between palliative care and intense EOL care, death location, and hospice were examined. RESULTS The median death age was 11 years; 62% were non-Hispanic White. Forty-one percent had a non-central nervous system (CNS) solid tumor. Fifty-eight percent received palliative care, and 36% received early palliative care (≥30 days before death). Children without relapsed/refractory disease were less likely to receive palliative care than those who had relapsed/refractory disease (adjusted odds ratio [aOR], 0.2; 95% confidence interval [CI], 0.1-0.7). Children with CNS tumors and hematologic malignancies were less likely to have early palliative care (aOR for CNS tumors, 0.4; 95% CI, 0.2-0.7; aOR for hematologic malignancies, 0.3; 95% CI, 0.2-0.7) than children with non-CNS solid tumors. Late palliative care (vs none) was associated with more medically intense care (aOR, 3.3; 95% CI, 1.4-7.8) and hospital death (aOR, 4.8; 95% CI, 1.9-11.6). Early palliative care (vs none) was associated with more hospice enrollment (aOR, 3.4; 95% CI, 1.5-7.6) but not medically intense care (aOR, 1.3; 95% CI, 0.6-2.9) or hospital death (aOR, 1.8; 95% CI, 0.8-3.7). CONCLUSIONS Fifty-eight percent of children dying of cancer in Alabama receive palliative care, but EOL care varies with the receipt and timing (early vs late) of palliative care. Whether this variation reflects differences in child and family preferences or systemic factors (eg, hospice access) remains unknown.
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Affiliation(s)
- Elizabeth S Davis
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Isaac Martinez
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Garrett Hurst
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Emily E Johnston
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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Outcomes following perinatal palliative care consultation: a retrospective review. J Perinatol 2021; 41:2196-2200. [PMID: 33597742 DOI: 10.1038/s41372-021-00966-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/08/2020] [Accepted: 01/26/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To inform clinical practice by describing a model of perinatal palliative care delivery within a fully staffed fetal health center (FHC) inside a freestanding children's hospital. STUDY DESIGN The team conducted a retrospective chart review of the palliative care team (PaCT) database from FHC's inception in 2010 to 31 December, 2018, and surveyed the FHC neonatologists. RESULTS PaCT consults in the FHC increased from 1 in 2010 to 102 in 2018. PaCT met 430 mothers for prenatal consultation. Of the 390 live-born infants, 172 died; 48 received comfort care only from birth; and 19 survived to discharge home with hospice. At the time of review, PaCT still follows 109 children met prenatally. PaCT discharged 96 patients that no longer required PaCT services. CONCLUSIONS PaCT provides an integral service within the FHC as evidenced by the increasing volume of consultations, variety of care provided and perceived value by FHC neonatologists.
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Patients requiring pediatric palliative care for advanced heart disease in France: A descriptive study. Arch Pediatr 2021; 28:548-552. [PMID: 34400053 DOI: 10.1016/j.arcped.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/10/2021] [Accepted: 06/13/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Pediatric palliative care (PPC) teams address unmet needs and improve the quality of life of patients with life-limiting conditions across pediatric subspecialties. However, little is known about the timing, reasons, and nature of PPC team interventions in advanced heart diseases (AHD). OBJECTIVES Here we describe how, when, and why PPC teams interact with referred teams of children suffering from AHD. METHODS We conducted a retrospective nationwide survey among PPC teams in France. All patients referred to participating PPC teams for a cardiologic disease in 2019 were studied. RESULTS Among six PPC teams, 18 patients with AHD had a PPC consultation in 2019. Six of these patients had cardiomyopathy and 12 had congenital heart disease (CHD). The median age at referral was 0.9 months for CHD and 72 months for cardiomyopathy. An antenatal diagnosis had been made for six families with CHD, and two of them were referred to PPC before birth allowing for a prenatal palliative care plan. The main reason for referral was ethical considerations (50%) followed by organization for home-based palliative care (28%). PPC teams participated in ethical discussions when asked to but also provided family support (12/18), home-based PPC (9/18), coordination of care (5/18), support of the referred team (4/18), and symptoms management (3/18) CONCLUSION: The main reason for referral to PPC was ethical considerations, but PPC interventions followed a holistic model of care. Prospective outcomes measurement and partnerships should be further developed.
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House TR, Wightman A. Adding Life to Their Years: The Current State of Pediatric Palliative Care in CKD. KIDNEY360 2021; 2:1063-1071. [PMID: 35373080 PMCID: PMC8791371 DOI: 10.34067/kid.0000282021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/05/2021] [Indexed: 01/16/2023]
Abstract
AbstractDespite continued advances in medical treatment, pediatric CKD remains an unremitting, burdensome condition characterized by decreased quality of life and earlier death. These burdens underscore the need for integration of pediatric palliative care (PPC) into nephrology practice. PPC is an evolving field that strives to (1) relieve physical, psychologic, social, practical, and existential suffering; (2) improve quality of life; (3) facilitate decision making; and (4) assist with care coordination in children with life-threatening or life-shortening conditions. Integration of palliative care into routine care has already begun for adults with kidney disease and children with other chronic diseases; however, similar integration has not occurred in pediatric nephrology. This review serves to provide a comprehensive definition of PPC, highlight the unmet need in pediatric nephrology and current integration efforts, discuss the state of palliative care in adult nephrology and analogous chronic pediatric disease states, and introduce future opportunities for study.
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Agosto C, Benedetti F, De Tommasi V, Milanesi O, Stellin G, Padalino MA, Benini F. End-of-life care for children with complex congenital heart disease: Parents' and medical care givers' perceptions. J Paediatr Child Health 2021; 57:696-701. [PMID: 33373473 DOI: 10.1111/jpc.15316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/05/2020] [Accepted: 11/21/2020] [Indexed: 11/27/2022]
Abstract
AIM In complex congenital heart diseases (CHD), patients may remain affected by significant morbidity and mortality after surgery. We analysed the end-of-life (EoL) care in children with severe CHD who died in our institution and investigated perspectives of parents and health-care professionals (HCPs). METHODS Medical records of all children (age < 18 years old) affected by a severe CHD who died in a tertiary cardiac care centre were reviewed. Subsequently, a cross-sectional questionnaire-based study of parents and HCPs of children involved in the study was designed. RESULTS In total, 30 children died (median age: 45 days; range: 15 days to 3.4 years). Of them, 97% (31/32) died in an intensive care unit setting and were intubated and sedated at EoL. A total of 77% (23/30) died without parents being present at bedside. Eighteen families and 10 HCPs were interviewed. For 61% of the parents (11/18) and 70% of the clinicians (7/10), the goal of therapy at the EoL was 'to lessen your child's suffering as much as possible'. Overall, 44% of parents (8/18) and 50% of HCPs recognised that their child had no chance of survival 'a few days before the child died'. CONCLUSIONS We believe that these data suggest an unconscious reluctance to change goals of care in EoL, shifting from intensive care to comfort and quality of life.
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Affiliation(s)
- Caterina Agosto
- Pediatric Pain and Palliative Care Service, Department of Women's and Children's Health, University Hospital, Padova, Italy
| | | | - Valentina De Tommasi
- Pediatric Pain and Palliative Care Service, Department of Women's and Children's Health, University Hospital, Padova, Italy
| | - Ornella Milanesi
- Division of Paediatric Cardiology, Department of Woman and Child's Health, University of Padova, Padova, Italy
| | - Giovanni Stellin
- Section of Paediatric and Congenital Cardiac Surgery, Department of Thoracic, Cardiac and Vascular Sciences, University of Padova, Padova, Italy
| | - Massimo A Padalino
- Section of Paediatric and Congenital Cardiac Surgery, Department of Thoracic, Cardiac and Vascular Sciences, University of Padova, Padova, Italy
| | - Franca Benini
- Pediatric Pain and Palliative Care Service, Department of Women's and Children's Health, University Hospital, Padova, Italy
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Klarare A, Carlsson T, Mattsson E. Belonging to a community of care: Mothers' experiences of online peer support groups for parents having lost a child with congenital heart defects. DEATH STUDIES 2020; 46:1741-1749. [PMID: 33252318 DOI: 10.1080/07481187.2020.1850548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The aim was to study mothers' experiences of online peer support groups after the death of a child. Participants (N = 8) were recruited through a newsletter for the Swedish association for families/children with heart defects, and two closed support groups on Facebook (900 and 100 members) and interviewed by telephone. Transcripts were analyzed with qualitative content analysis. The groups were available around the clock, regardless of support need, and mothers joined both to receive and provide support. Participation in online peer support groups may provide a sense of belonging to a caring community and serve as a valuable complement to healthcare.
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Affiliation(s)
- Anna Klarare
- Clinical psychology in healthcare, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Tommy Carlsson
- Clinical psychology in healthcare, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- The Swedish Red Cross University College, Huddinge, Sweden
| | - Elisabet Mattsson
- Clinical psychology in healthcare, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
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Knight Lozano R, May S, Clarkson C, Sarjeant R. Caregiver experiences of paediatric inpatient cardiac services: A qualitative systematic review. Eur J Cardiovasc Nurs 2020; 20:147-159. [PMID: 33849062 DOI: 10.1177/1474515120951974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/04/2020] [Accepted: 08/02/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Advances in paediatric care have contributed to an increasing survival of children with complex heart disease. Yet, life-saving management demands prolonged inpatient admissions, which contribute to emotional and psychological distress for parents and other caregivers in a role of main custody. AIM The purpose of this study was to identify, appraise and synthesise qualitative studies exploring caregivers' experiences of paediatric inpatient cardiac services, generating an understanding of their needs in hospital and informing priorities for change in healthcare delivery. METHODS Searches were conducted in Medline, Allied and Complimentary Medicine Database, Cumulative Index of Nursing and Allied Health Literature, EMCARE, Scopus, PsychINFO, Proquest, OpenGrey and ETHOs from 2008-2019, reflecting recent advances in cardiac healthcare. Articles were selected using predetermined eligibility criteria dictating qualitative inquiry into caregiver perspectives whilst their child received hospital-based interventions for heart disease. All eligible studies underwent quality appraisal. Framework synthesis was used to analyse and summarise findings. RESULTS Twenty-seven studies involving 689 caregivers from 11 countries were included. Three overarching themes were identified: 'emotional capacity to care', 'practicalities of caring', and 'the bigger picture of caring'. CONCLUSIONS Through analysis and summary of qualitative primary research, this review captures the emotional challenges that caregivers face and practicalities of undertaking a caregiver role, whilst looking after their child with heart disease in hospital. The results widen the context of the caregiver role, encompassing the whole family unit beyond the hospital environment. This review exposes the impact of these challenges on caregiver competence, wellbeing and attachment to their unwell child, informing priorities for development of family-centred paediatric inpatient cardiac services.
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Affiliation(s)
| | - Stephen May
- Faculty of Health and Wellbeing, Sheffield Hallam University, UK
| | - Carl Clarkson
- Department of Sport, Exercise and Rehabilitation, Northumbria University, UK
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Wan A, Weingarten K, Rapoport A. Palliative Care?! But This Child's Not Dying: The Burgeoning Partnership Between Pediatric Cardiology and Palliative Care. Can J Cardiol 2020; 36:1041-1049. [PMID: 32437731 DOI: 10.1016/j.cjca.2020.04.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/16/2020] [Accepted: 04/27/2020] [Indexed: 11/16/2022] Open
Abstract
The field of pediatric cardiology has witnessed major changes over the past few decades that have considerably altered patient outcomes, including decreasing mortality rates for many previously untreatable conditions. Despite this, some pediatric cardiology programs are increasingly choosing to partner with their institutional palliative care teams. Why is this? The field of palliative care also has experienced significant shifts over a similar period of time. Today's palliative care is focused on improving quality of life for any patient with a serious or life-threatening condition, regardless of where they might be on their disease trajectory. Research has clearly demonstrated that improved outcomes can be achieved for a variety of patient cohorts through early integration of palliative care; recent evidence suggests that the same may be true in pediatric cardiology. All pediatric cardiologists need to be aware of what pediatric palliative care has to offer their patients, especially those who are not actively dying. This manuscript reviews the evolution of palliative care and provides a rationale for its integration into the care of children with advanced heart disease. Readers will gain a sense of how and when to introduce palliative care to their families, as well as insight into what pediatric palliative care teams have to offer. Additional research is required to better delineate optimal partnerships between palliative care and pediatric cardiology so that we may promote maximal quality of life for patients concurrently with continued efforts to push the boundaries of quantity of life.
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Affiliation(s)
- Andrea Wan
- Division of Cardiology, Hospital for Sick Children, Toronto, Canada; Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Kevin Weingarten
- Department of Paediatrics, University of Toronto, Toronto, Canada; Paediatric Advanced Care Team, Hospital for Sick Children, Toronto, Canada
| | - Adam Rapoport
- Paediatric Advanced Care Team, Hospital for Sick Children, Toronto, Canada; Emily's House Children's Hospice, Toronto, Canada; Departments of Paediatrics and Family and Community Medicine, University of Toronto, Toronto, Canada.
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Early for Everyone: Reconceptualizing Palliative Care in the Neonatal Intensive Care Unit. Adv Neonatal Care 2020; 20:109-117. [PMID: 31990696 DOI: 10.1097/anc.0000000000000707] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Palliative care (PC) in the neonatal intensive care unit (NICU) is often provided exclusively to infants expected to die. Standards of care support providing PC early after diagnosis with any condition likely to impact quality of life. PURPOSE To determine the state of early PC practice across populations to derive elements of early PC applicable to neonates and their families and demonstrate their application in practice. SEARCH STRATEGY Multiple literature searches were conducted from 2016 to 2019. Common keywords used were: palliative care; early PC; end of life, neonate; NICU; perinatal PC; pediatric PC; family-centered care; advanced care planning; palliative care consultant; and shared decision-making. FINDINGS Early PC is an emerging practice in adult, pediatric, and perinatal populations that has been shown to be helpful for and recommended by families. Three key elements of early PC in the NICU are shared decision-making, care planning, and coping with distress. A hypothetical case of a 24-week infant is presented to illustrate how findings may be applied. Evidence supports expansion of neonatal PC to include infants and families without terminal diagnoses and initiation earlier in care. IMPLICATIONS FOR PRACTICE Involving parents more fully in care planning activities and decision-making and providing structured support for them to cope with distress despite their child's prognosis are essential to early PC. IMPLICATIONS FOR RESEARCH As early PC is incorporated into practice, strategies should be evaluated for feasibility and efficacy to improve parental and neonatal outcomes. Researchers should consider engaging NICU parent stakeholders in leading early PC program development and research.
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Abstract
OBJECTIVE Hypoplastic left heart syndrome is a single ventricle defect. While staged surgical palliative treatments have revolutionised care, patients with hypoplastic left heart syndrome continue to have significant morbidity and mortality. In 2017, the National Pediatric Cardiology Quality Improvement Collaborative recommended all single ventricle patients to receive a prenatal palliative care consult. This study aimed to elucidate provider perspectives on the implementation of prenatal palliative care consults for families expecting a child with hypoplastic left heart syndrome. METHODS An online survey was administered to obstetric and paediatric providers of relevant disciplines to assess their experience with palliative care involvement in hypoplastic left heart syndrome cases. RESULTS Nearly, all physicians (97%) and most registered nurses (79%) agreed that the initial palliative care consult for patients with hypoplastic left heart syndrome should occur during the prenatal period. Respondents also indicated that prenatal palliative care consults should also be offered in a variety of other CHD conditions. Participants believed positive aspects of this new referral protocol included an expanded support network for families, decreased family stress during the postnatal period, increased patient education about what to expect during the postnatal period, and continuity of care. CONCLUSION Multidisciplinary healthcare professionals believe that prenatal palliative care consults provide a variety of benefits for patients and families with hypoplastic left heart syndrome. Additional, multi-centre research is necessary to evaluate whether prenatal palliative care consults should become standard of care for families expecting a child with a single ventricle defect.
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Zentner D, Celermajer DS, Gentles T, d’Udekem Y, Ayer J, Blue GM, Bridgman C, Burchill L, Cheung M, Cordina R, Culnane E, Davis A, du Plessis K, Eagleson K, Finucane K, Frank B, Greenway S, Grigg L, Hardikar W, Hornung T, Hynson J, Iyengar AJ, James P, Justo R, Kalman J, Kasparian N, Le B, Marshall K, Mathew J, McGiffin D, McGuire M, Monagle P, Moore B, Neilsen J, O’Connor B, O’Donnell C, Pflaumer A, Rice K, Sholler G, Skinner JR, Sood S, Ward J, Weintraub R, Wilson T, Wilson W, Winlaw D, Wood A. Management of People With a Fontan Circulation: a Cardiac Society of Australia and New Zealand Position statement. Heart Lung Circ 2020; 29:5-39. [DOI: 10.1016/j.hlc.2019.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
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Callahan K, Steinwurtzel R, Brumarie L, Schechter S, Parravicini E. Early palliative care reduces stress in parents of neonates with congenital heart disease: validation of the "Baby, Attachment, Comfort Interventions". J Perinatol 2019; 39:1640-1647. [PMID: 31488903 DOI: 10.1038/s41372-019-0490-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/17/2019] [Accepted: 07/26/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To test our hypothesis that an innovative method of early palliative care called "Baby, Attachment, Comfort Interventions" reduces psychological distress in parents of neonates with congenital heart disease. STUDY DESIGN Prospective cohort study of parents of neonates with congenital heart disease. Distress was evaluated at admission and discharge using Neonatal Unit Parental Stressor Scale and Depression Anxiety Stress Index-21. Control parents received standard of care. Intervention parents received interdisciplinary interventions aimed at improving neonatal comfort and parenting experience. RESULTS Seventy-seven parents participated. Stress decreased in the intervention group (26 parents) but not in the control group (51 parents). There was no decrease in anxiety or depression in either group. CONCLUSION Early palliative care reduces stress in parents of neonates with congenital heart disease. Further work is needed to address depression/anxiety in this group of high-risk parents.
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Affiliation(s)
- Katharine Callahan
- Department of Pediatrics, Columbia University Irving Medical Center/NewYork-Presbyterian, New York, NY, USA. .,Children's Hospital of Philadelphia, Division of Neonatology, Philadelphia, PA, USA.
| | - Rochelle Steinwurtzel
- Department of Pediatrics, Columbia University Irving Medical Center/NewYork-Presbyterian, New York, NY, USA
| | | | - Sarah Schechter
- Department of Pediatrics, Columbia University Irving Medical Center/NewYork-Presbyterian, New York, NY, USA
| | - Elvira Parravicini
- Department of Pediatrics, Columbia University Irving Medical Center/NewYork-Presbyterian, New York, NY, USA
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Joong A, Derrington SF, Patel A, Thrush PT, Allen KY, Marino BS. Providing Compassionate End of Life Care in the Setting of Mechanical Circulatory Support. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00206-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
PURPOSE OF REVIEW Advanced heart failure in children is characterized by dynamic clinical trajectories, uncertainty of prognosis, and intermittent need for difficult decision-making, often related to novel therapeutic interventions with uncertain impact on quality of life. This review will examine the current role of palliative care to support this unique population. RECENT FINDINGS Pediatric heart failure patients commonly die in ICUs with high burden of invasive therapies together with end of life care needs. In addition, several studies advocate for integration of palliative care early in disease trajectory, not only focused on end of life care. Many advocate for the core tenets of palliative care (symptom management, communication of prognosis, and advanced care planning) to be provided by the primary cardiology team, with consultation by pediatric palliative care specialists. There is also a consensus that palliative care training should be incorporated into pediatric advanced heart disease training programs. SUMMARY Palliative care is an important component of pediatric heart failure care. Research and quality improvement efforts are needed to determine the most effective palliative care interventions for children with advanced heart disease. Provision of palliative care is an essential component of training for pediatric heart failure and transplant specialists.
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Morell E, Moynihan K, Wolfe J, Blume ED. Palliative care and paediatric cardiology: current evidence and future directions. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:502-510. [PMID: 31126897 DOI: 10.1016/s2352-4642(19)30121-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/20/2019] [Accepted: 02/27/2019] [Indexed: 12/24/2022]
Abstract
Although outcomes for children with heart disease have improved substantially over the past several decades, heart disease remains one of the leading causes of paediatric mortality. For children who progress to advanced heart disease, disease morbidity is high, with many children requiring multiple surgical interventions and long-term intensive care hospitalisations. Care for children with advanced heart disease requires a multidisciplinary approach, and opportunities for earlier integration of palliative care are being explored. This Viewpoint summarises the relevant literature over the past decade. We also identify gaps in parent and provider understanding of prognosis and communication, propose indications for palliative care consultation in paediatric advanced heart disease, and summarise attitudes and perceived barriers to palliative care consultation. Areas for additional research that we identify include paediatric cardiologist education, parental distress, socioeconomic disparities, and patient-reported outcomes. Interdisciplinary clinical and research efforts are required to further advance the field and improve integration of palliative care in the care of children with heart disease.
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Affiliation(s)
- Emily Morell
- Division of Pediatric Critical Care, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Katie Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Joanne Wolfe
- Pediatric Palliative Care, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
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Jersak T, Gustin J, Humphrey L. Challenges of the Transition: A Case of Noncompliance in an Adult with Congenital Heart Disease. J Palliat Med 2019; 22:1621-1623. [PMID: 31090489 DOI: 10.1089/jpm.2018.0467] [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] [Indexed: 11/12/2022] Open
Abstract
There are more adults than children living with congenital heart disease (CHD) due to improvements in surgical and medical CHD management today. In 2011, though, fewer than 30% of adult CHD patients were following up with specialized providers. An ineffective transition from pediatric to adult-focused medical care can result in lapses in CHD medical care, patient noncompliance, and increased risk of late complications. Early involvement of a palliative care team offers development of autonomy, identification of potential barriers to care, and support for patient and family that may improve transition success and quality of life in CHD patients.
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Affiliation(s)
- Taylor Jersak
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jillian Gustin
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lisa Humphrey
- Division of Palliative Medicine, Department of Anesthesia, Nationwide Children's Hospital, Columbus, Ohio
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Goloff N, Joy BF. A part of the team: The changing role of palliative care in congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kitzmiller L, Kline-Tilford AM. Supporting the family left behind – Loss of a child to congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Edwards LA, Bui C, Cabrera AG, Jarrell JA. Improving outpatient advance care planning for adults with congenital or pediatric heart disease followed in a pediatric heart failure and transplant clinic. CONGENIT HEART DIS 2018; 13:362-368. [DOI: 10.1111/chd.12579] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/26/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Lindsay A. Edwards
- Texas Children's Hospital; Lillie Frank Abercrombie Section of Pediatric Cardiology; Houston Texas USA
- Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
| | - Christine Bui
- Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
- Department of Medicine; Baylor College of Medicine; Houston Texas USA
| | - Antonio G. Cabrera
- Texas Children's Hospital; Lillie Frank Abercrombie Section of Pediatric Cardiology; Houston Texas USA
- Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
| | - Jill Ann Jarrell
- Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
- Section of Academic General Pediatrics; Texas Children's Hospital; Houston Texas USA
- Texas Children's Hospital; Section of Palliative Care; Houston Texas USA
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Marcus KL, Balkin EM, Al-Sayegh H, Guslits E, Blume ED, Ma C, Wolfe J. Patterns and Outcomes of Care in Children With Advanced Heart Disease Receiving Palliative Care Consultation. J Pain Symptom Manage 2018; 55:351-358. [PMID: 28887267 DOI: 10.1016/j.jpainsymman.2017.08.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 08/29/2017] [Accepted: 08/29/2017] [Indexed: 11/24/2022]
Abstract
CONTEXT Although access to subspecialty pediatric palliative care (PPC) is increasing, little is known about the role of PPC for children with advanced heart disease (AHD). OBJECTIVES The objective of this study was to examine features of subspecialty PPC involvement for children with AHD. METHODS This is a retrospective single-institution medical record review of patients with a primary diagnosis of AHD for whom the PPC team was initially consulted between 2011 and 2016. RESULTS Among 201 patients, 87% had congenital/structural heart disease, the remainder having acquired/nonstructural heart disease. Median age at initial PPC consultation was 7.7 months (range 1 day-28.8 years). Of the 92 patients who were alive at data collection, 73% had received initial consultation over one year before. Most common indications for consultation were goals of care (80%) and psychosocial support (54%). At initial consultation, most families (67%) expressed that their primary goal was for their child to live as long and as comfortably as possible. Among deceased patients (n = 109), median time from initial consultation to death was 33 days (range 1 day-3.6 years), and children whose families expressed that their primary goal was for their child to live as comfortably as possible were less likely to die in the intensive care unit (P = 0.03) and more likely to die in the setting of comfort care or withdrawal of life-sustaining interventions (P = 0.008). CONCLUSION PPC involvement for children with AHD focuses on goals of care and psychosocial support. Findings suggest that PPC involvement at end of life supports goal-concordant care. Further research is needed to clarify the impact of PPC on patient outcomes.
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Affiliation(s)
- Katherine L Marcus
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Emily M Balkin
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California, USA
| | - Hasan Al-Sayegh
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Elyssa Guslits
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.
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May R, Thompson J. The Role of Pediatric Palliative Care in Complex Congenital Heart Disease: Three Illustrative Cases. J Palliat Med 2017; 20:1300-1303. [DOI: 10.1089/jpm.2017.0047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Rachna May
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jess Thompson
- Department of Cardiothoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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