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Jarrell JA, Grossoehme DH, Friebert S, Ajayi TA, Thienprayoon R, Humphrey L. Challenges in Home-Based Pediatric Hospice and Palliative Care: A Case Series. J Pain Symptom Manage 2024:S0885-3924(24)00849-2. [PMID: 38972553 DOI: 10.1016/j.jpainsymman.2024.06.027] [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] [Received: 03/04/2024] [Revised: 06/27/2024] [Accepted: 06/30/2024] [Indexed: 07/09/2024]
Abstract
Pediatric home-based hospice and palliative care is a growing and important sub-field within the larger pediatric palliative care landscape. Despite research demonstrating the clinical and systemic efficacy of pediatric home-based hospice and palliative care, there remain barriers to its optimal development, implementation, and dissemination and best clinical practice knowledge gaps. This case series presents specific examples of ubiquitous challenges in pediatric home-based hospice and palliative care in hopes of guiding future research, education, advocacy, and program development efforts.
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Affiliation(s)
- Jill Ann Jarrell
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX USA.
| | - Daniel H Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, OH USA
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, OH USA
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2
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Linane H, Tanjavur B, Sullivan L. A scoping review of guidelines and frameworks for advance care planning for adolescents and young adults with life-limiting or life-threatening conditions. Palliat Med 2024; 38:504-516. [PMID: 38600067 DOI: 10.1177/02692163241242331] [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: 04/12/2024]
Abstract
BACKGROUND Advance care planning discussions are crucial in the management and support of individuals with life-limiting or life-threatening conditions. Few studies have examined best practices for advance care planning with adolescents and young adults. AIM To identify core components of current guidelines, frameworks and tools for advance care planning discussions with adolescents and young adults with life-limiting or life-threatening conditions and their families. DESIGN A scoping review of the literature was conducted followed by a thematic analysis of the included papers. The scoping review was reported according to the Joanna Briggs Institute approach to the conduct of scoping reviews. DATA SOURCES Five databases [Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, PsycInfo, PubMed and Scopus] were searched for English-language papers published between inception until January 2023. RESULTS The search yielded 2976 papers, of which 9 met the inclusion criteria. Five main themes were identified: (i) utilisation of standardised documents and protocols; (ii) shared decision-making between the adolescents and young adults, their families and the healthcare team; (iii) the importance of open and honest communication with adolescents and young adults during advance care planning discussions; (iv) individualisation and flexibility in the advance care planning process and (v) timing of advance care planning initiation. CONCLUSIONS Results highlight the importance of engaging adolescents and young adults in advance care planning and considering their unique needs when initiating and framing these discussions. Our findings can be used by healthcare professionals to inform advance care planning in this group.
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Affiliation(s)
- Hannah Linane
- Department of Paediatric Palliative Medicine, Children's Health Ireland, Dublin, Ireland
| | - Bhavana Tanjavur
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Lindsay Sullivan
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, USA
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3
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Aasen ERHV, Søvik ML, Størdal K, Lee A. Are We on the Same Page? Exploring Pediatric Patients' Involvement With Advance Care Planning. J Pain Symptom Manage 2023; 66:e353-e363. [PMID: 37054956 DOI: 10.1016/j.jpainsymman.2023.04.003] [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: 02/06/2023] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND According to the UN Convention on the Rights of the Child, children have a right to be heard. This also applies to patients in pediatric palliative care (PPC). The aim of this literature review was to explore what is known about the involvement of children (<14 years of age), adolescents and young adults (AYAs) in advance care planning (ACP) in PPC. METHODS A search was conducted in PubMed including publications from January 1, 2002 until December 31, 2021. The identified citations had to report on ACP or related terms in any PPC context. RESULTS A total of n = 471 unique reports were identified. Final inclusion criteria were met by n = 21 reports, including children and AYAs with diagnoses related to oncology, neurology, HIV/AIDS and cystic fibrosis. Nine reports were from randomized controlled studies, investigating ACP methodology. The main findings were: 1) caregivers are included more often than children and adolescents in ACP, 2) some studies indicate an incongruence between AYAs and their caregivers regarding ACP and treatment preferences, 3) although the process evokes a wide range of emotions, ACP is perceived as helpful by many AYAs CONCLUSION: The majority of studies about ACP in PPC do not include children and AYAs. Whether incongruence reported in some studies between AYAs and their caregivers regarding treatment preferences could be reduced by ACP should be further explored, including the involvement of children and adolescents in ACP, and the impact of pediatric ACP on patient outcomes in PPC.
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Affiliation(s)
| | - Marte Løvaas Søvik
- Faculty of Medicine (E.R.H.V.A., M.L.S.), University of Oslo, Oslo, Norway
| | - Ketil Størdal
- Department of Pediatric Research (K.S.), Faculty of Medicine, University of Oslo, Oslo, Norway; Division of Pediatric and Adolescent Medicine (K.S., A.L.), Oslo University Hospital, Oslo, Norway
| | - Anja Lee
- Division of Pediatric and Adolescent Medicine (K.S., A.L.), Oslo University Hospital, Oslo, Norway.
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4
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Abdelaal M, Avery J, Chow R, Saleem N, Fazelzad R, Mosher P, Hannon B, Zimmermann C, Al-Awamer A. Palliative care for adolescents and young adults with advanced illness: A scoping review. Palliat Med 2023; 37:88-107. [PMID: 36352490 PMCID: PMC9841827 DOI: 10.1177/02692163221136160] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Age-related complex medical conditions have been commonly reported among adolescents and young adults with advanced life-limiting illness. There is increasing interest in exploring their palliative care needs and end-of-life experiences. AIM This scoping review aimed to explore the available literature about providing palliative and end-of-life care to adolescents and young adults with advanced life-limiting illnesses. DESIGN Scoping review. This review was registered on Open Science Framework (https://doi.org/10.17605/OSF.IO/SPTD7). DATA SOURCES Electronic databases (MEDLINEALL, Embase, Emcare, Cochrane Central Register of Controlled Trial CENTRAL, Scopus, PsycINFO, Cochrane Database of Systematic Reviews), Google Scholar and reference lists were searched up to October 2021. We included studies reporting on adolescents and/or young adults with advanced life-limiting illnesses. There were no limitations concerning location, type of illness or study design. RESULTS We identified 51 studies published between 2002 and 2021. Most studies were published in the United States (n = 34, 67%), and nine studies (18%) reported exclusively on patients with non-malignant illnesses. Two thirds of the identified studies were case reports and retrospective chart reviews (n = 33). Three main topics were identified: Physical symptom burden (n = 26, 51%), Psychological and social needs (n = 33, 65%), and end-of-life care (n = 30, 59%). Twenty-six studies (51%) were focused only on one topic, and the age range used to identify adolescents and young adults varied based on the study location. CONCLUSION The findings of this review shed light on the different palliative care experiences and knowledge gaps related to adolescents and young adults as an underserved and vulnerable patient population. Further research needs to be dedicated toward palliative care programs tailored for adolescents and young adults.
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Affiliation(s)
- Mohamed Abdelaal
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jonathan Avery
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Ronald Chow
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nasreen Saleem
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rouhi Fazelzad
- UHN Library and Information Services, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Pamela Mosher
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Child and Adolescent Psychiatry, Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ahmed Al-Awamer
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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5
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Trang J, Herbert A, Sansom-Daly UM. How can advance care planning tools help young people's voices be heard? J Paediatr Child Health 2022; 58:1317-1322. [PMID: 35758055 DOI: 10.1111/jpc.16095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 05/23/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022]
Abstract
The integration of the child or young person (CYP) in conversations around advance care planning (ACP) is an important area of paediatric practice. These discussions provide CYP with the opportunity to voice their values, goals and preferences, enabling health-care professionals to ensure they are aligned with their planned course of treatment. This process, often undertaken within the context of the child's family, empowers children to participate in decisions and experience the dignity of self-determination. It also facilitates an increased understanding between the CYP and those involved in their care. The objectives of this paper are to highlight the importance of these conversations for paediatricians and identify barriers, both real and perceived, that may prevent them from engaging with a CYP about their preferences for future care including focusing more on discussion with the parents, and concern about or not having the skills to engage the child in such sensitive conversations. Triggers that can prompt clinicians to undertake ACP are also discussed. A further complexity is that after seeking their perspective, it may become apparent that the CYP may hold different views and perspectives to their parents and/or clinician. This review article will especially examine elements of end-of-life conversations that are critical to support the important goal of listening to the voice of the CYP. This includes considerations around timing, legal aspects, ethical tensions that arise when amplifying a child's voice, clinician/team-member roles, clinical process considerations, and the use of specific interventions and ACP tools to facilitate these conversations with CYP.
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Affiliation(s)
- Jacinta Trang
- Children's Health Queensland Hospital and Health Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Anthony Herbert
- Children's Health Queensland Hospital and Health Service, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Centre for Children's Health Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ursula M Sansom-Daly
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia.,Discipline of Paediatrics, School of Clinical Medicine, UNSW Medicine & Health, Randwick Clinical Campus, University of New South Wales Sydney, Sydney, New South Wales, Australia.,Sydney Youth Cancer Service, Prince of Wales/Sydney Children's Hospital, Sydney, New South Wales, Australia
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6
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Baker JN, Friebert S, Needle J, Jiang J, Wang J, Lyon ME. An Intervention in Congruence for End-of-Life Treatment Preference: A Randomized Trial. Pediatrics 2022; 149:e2021054796. [PMID: 35425986 PMCID: PMC9648108 DOI: 10.1542/peds.2021-054796] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is a gap in family knowledge of their adolescents' end-of-life (EOL) treatment preferences. We tested the efficacy of Family Centered Advance Care Planning for Teens with Cancer (FACE-TC) pediatric advance care planning (to increase congruence in EOL treatment preferences. METHODS Adolescents with cancer/family dyads were randomized into a clinical trial from July 2016 to April 2019 at a 2:1 ratio: intervention (n = 83); control (n = 43) to either 3 weekly sessions of FACE-TC (Lyon Advance Care Planning Survey; Next Steps: Respecting Choices Interview; Five Wishes, advance directive) or treatment as usual (TAU). Statement of Treatment Preferences measured congruence. RESULTS Adolescents' (n = 126) mean age was 16.9 years; 57% were female and 79% were White. FACE-TC dyads had greater overall agreement than TAU: high 34% vs 2%, moderate 52% vs 45%, low 14% vs 52%, and P < .0001. Significantly greater odds of congruence were found for FACE-TC dyads than TAU for 3 of 4 disease-specific scenarios: for example, "a long hospitalization with low chance of survival," 78% (57 of 73) vs 45% (19 of 42); odds ratio, 4.31 (95% confidence interval, 1.89-9.82). FACE-TC families were more likely to agree to stop some treatments. Intervention adolescents, 67% (48 of 73), wanted their families to do what is best at the time, whereas fewer TAU adolescents, 43% (18 of 42), gave families this leeway (P = .01). CONCLUSIONS High-quality pediatric advance care planning enabled families to know their adolescents' EOL treatment preferences.
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Affiliation(s)
- Justin N. Baker
- Division of Quality of Life and Palliative Care, St. Jude
Children’s Research Hospital, Memphis, Tennessee
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center
- Rebecca D. Considine Research Institute, Akron
Children’s Hospital, Akron, Ohio
| | - Jennifer Needle
- Department of Pediatrics and Center for Bioethics,
University of Minnesota, Minneapolis, Minnesota
| | - JiJi Jiang
- Henry M. Jackson Foundation for the Advancement of
Military Medicine, Bethesda, Maryland
| | - Jichuan Wang
- Divisions of Biostatistics and Study Methodology
- Center for Translational Research/Children’s
National Research Institute, Children’s National Hospital, Washington,
DC
| | - Maureen E. Lyon
- Adolescent and Young Adult Medicine
- Center for Translational Research/Children’s
National Research Institute, Children’s National Hospital, Washington,
DC
- Department of Pediatrics, George Washington University
School of Medicine and Health Sciences, Washington, DC
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7
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Hansen K, Edwards LA, Yohannes K, Luong R, Lin A, Long J, Halpern-Felsher B, Cohen H, Kaufman BD. Advance Care Planning Preferences for Adolescents With Cardiac Disease. Pediatrics 2022; 149:184391. [PMID: 34984466 DOI: 10.1542/peds.2020-049902] [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] [Accepted: 11/02/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Adolescents with cardiac disease are at risk for life-changing complications and premature death. The importance of advance care planning (ACP) in adults with congenital heart disease and in pediatric patients with HIV and cancer has been demonstrated. ACP preferences of adolescents with heart disease have not been evaluated. We describe ACP preferences of adolescents with heart disease and compare with those of their caregivers. METHODS Outpatient adolescents aged 12 to 18 years with heart failure, cardiomyopathy, heart transplantation, or who were at risk for cardiomyopathy, as well as their caregivers, completed self-administered questionnaires which evaluated participants' opinions regarding content and timing of ACP discussions, preferences for end-of-life communication, and emotional responses to ACP. RESULTS Seventy-eight adolescents and 69 caregivers participated, forming 62 adolescent-caregiver dyads. Adolescents and caregivers reported that adolescent ACP discussions should occur early in the disease course (75% and 61%, respectively). Adolescents (92%) wanted to be told about terminal prognosis, whereas only 43% of caregivers wanted the doctor to tell their child this information. Most adolescents (72%) and caregivers (67%) anticipated that discussing ACP would make the adolescent feel relieved the medical team knew their wishes. Most caregivers (61%) believed that adolescents would feel stress associated with ACP discussions, whereas only 31% of adolescents anticipated this. CONCLUSIONS Adolescents and their caregivers agree that ACP should occur early in disease course. There are discrepancies regarding communication of prognosis and perceived adolescent stress related to ACP discussions. Facilitated conversations between patient, caregiver, and providers may align goals of care and communication preferences.
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Affiliation(s)
| | - Lindsay A Edwards
- Divisions of Cardiology.,Division of Cardiology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | | | | | - Amy Lin
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jin Long
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Bonnie Halpern-Felsher
- Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
| | - Harvey Cohen
- Division of Hematology/Oncology, Lucile Packard Children's Hospital Stanford, Palo Alto, California
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8
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Grill KB, Wang J, Scott RK, Benator D, D'Angelo LJ, Lyon ME. What Do Adults With HIV Want? End-of-Life Care Goals, Values and Beliefs by Gender, Race, Sexual Orientation. Am J Hosp Palliat Care 2021; 38:610-617. [PMID: 33464114 DOI: 10.1177/1049909120988282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE We examined factors influencing end-of-life care preferences among persons living with HIV (PLWH). METHODS 223 PLWH were enrolled from 5 hospital-based clinics in Washington, DC. They completed an end-of-life care survey at baseline of the FACE™-HIV Advance Care Planning clinical trial. FINDINGS The average age of patients was 51 years. 56% were male, 66% heterosexual, and 86% African American. Two distinct groups of patients were identified with respect to end-of-life care preferences: (1) a Relational class (75%) who prioritized family and friends, comfort from church services, and comfort from persons at the end-of-life; and (2) a Transactional/Self-Determination class (25%) who prioritized honest answers from their doctors, and advance care plans over relationships. African Americans had 3x the odds of being in the Relational class versus the Transactional/Self-determination class, Odds ratio = 3.30 (95% CI, 1.09, 10.03), p = 0.035. Males were significantly less likely to be in the relational latent class, Odds ratio = 0.38 (CI, 0.15, 0.98), p = 0.045. Compared to non-African-Americans, African-American PLWH rated the following as important: only taking pain medicines when pain is severe, p = 0.0113; saving larger doses for worse pain, p = 0.0067; and dying in the hospital, p = 0.0285. PLWH who were sexual minorities were more afraid of dying alone, p = 0.0397, and less likely to only take pain medicines when pain is severe, p = 0.0091. CONCLUSION Integrating culturally-sensitive palliative care services as a component of the HIV care continuum may improve health equity and person-centered care.
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Affiliation(s)
| | - Jichuan Wang
- Division of Biostatistics and Study Methodology, Center for Translational Research at Children's National Hospital, Washington, DC, USA.,George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Rachel K Scott
- MedStar Health Research Institute and Washington Hospital Center, Washington, DC, USA
| | - Debra Benator
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Washington DC Veterans Affairs Medical Center, Washington, DC, USA
| | - Lawrence J D'Angelo
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Division of Adolescent and Young Adult Medicine, 571630Children's National Hospital, Washington, DC, USA
| | - Maureen E Lyon
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Division of Adolescent and Young Adult Medicine, 571630Children's National Hospital, Washington, DC, USA.,Center for Translational Research/Children's National Research Institute at 571630Children's National Hospital, Washington, DC, USA
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9
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Li Y, Whelan CM, Husain AF. Deprescribing in the Home Palliative Setting. J Palliat Med 2020; 24:1030-1035. [PMID: 33326319 DOI: 10.1089/jpm.2020.0376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: When patients' goals of care have shifted toward comfort, treatment should focus on alleviating symptoms rather than prolonging life at the expense of comfort. Objective: To determine whether the number of noncomfort medications is associated with deprescribing in patients seen by a home-visiting palliative care physician. Design: Single-centre retrospective chart review of patients cared for in the home setting by a specialty palliative care program to determine factors associated with deprescribing. All medications on initial consult were classified as comfort, possibly for comfort, and definitely not for comfort (DNC). Patients were stratified depending on whether intentional deprescribing occurred. Data were analyzed for associations between deprescribing and other variables: number and proportion of DNC medications, diagnosis, palliative performance scale (PPS), number of encounters, code status, preferred place of death, and time to death. Setting: Study population included 80 patients followed by specialist home-visiting palliative physicians in a tertiary center. Inclusion criteria were adult patients with PPS ≤60%, initially seen by a home-visiting palliative physician between 2016 and 2018 and followed for at least 60 days or until death. Results: Deprescribing occurred in 44% of study patients within 60 days. Median number of DNC medications was 3 in the deprescribed group and 0 in the nondeprescribed group (p < 0.001). Proportion of DNC medications was 29% in the deprescribed group and 15% in the nondeprescribed group (p < 0.01). Conclusions: Deprescribing is associated with an increased number and proportion of DNC medications at the time of initial in-home palliative assessment. Deprescribing rates varied greatly between different home-visiting palliative providers.
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Affiliation(s)
- Yifan Li
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ciara M Whelan
- Temmy Latner Centre for Palliative Care, Sinai Health Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada
| | - Amna F Husain
- Temmy Latner Centre for Palliative Care Lunenfeld Tanenbaum Research Institute, Sinai Health Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada
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10
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Johnston EE, Martinez I, Currie E, Brock KE, Wolfe J. Hospital or Home? Where Should Children Die and How Do We Make That a Reality? J Pain Symptom Manage 2020; 60:106-115. [PMID: 31887402 DOI: 10.1016/j.jpainsymman.2019.12.370] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 01/31/2023]
Abstract
CONTEXT Most of the 20,000 U.S. children dying of serious illnesses annually die in the hospital. It is unknown if this hospital death predominance reflects family wishes or systemic issues such as lack of hospice access. Hence, we need to better understand location of death preferences for children and their families. OBJECTIVE To better understand location of death preferences in North America, we reviewed the literature to examine the evidence for and against home death in seriously ill children (0-18 years). METHODS We searched English articles in PubMed, PsycINFO, and Embase published during 2000-2018 for articles related to parental, child/adolescent, and provider preference for death location and articles that correlated death location with bereavement or quality of life outcomes. RESULTS The search results (n = 877 articles and n = 58 abstracts of interest) were reviewed, and 34 relevant articles were identified. Parent, child, and provider preferences, bereavement outcomes, and associated factors all point to some preference for home death. These findings should be interpreted with several caveats: 1) many studies are small and prone to selection bias, 2) not all families prefer home death and some that do are not able to achieve home death due to inadequate home support, 3) studies of bereavement outcomes are lacking. CONCLUSION Adequate resources are needed to ensure children can die in their chosen location-be that home, hospital, or free-standing hospice. This review highlights research areas needed to better understand death location preference and programs and policies that will support home death for those that desire it.
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Affiliation(s)
- Emily E Johnston
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - Isaac Martinez
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erin Currie
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katharine E Brock
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA; Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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11
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Friebert S, Grossoehme DH, Baker JN, Needle J, Thompkins JD, Cheng YI, Wang J, Lyon ME. Congruence Gaps Between Adolescents With Cancer and Their Families Regarding Values, Goals, and Beliefs About End-of-Life Care. JAMA Netw Open 2020; 3:e205424. [PMID: 32427325 PMCID: PMC7237980 DOI: 10.1001/jamanetworkopen.2020.5424] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/13/2020] [Indexed: 11/14/2022] Open
Abstract
Importance Lack of pediatric advance care planning has been associated with poor communication, increased hospitalization, poor quality of life, and legal actions. Clinicians presume that families understand adolescents' treatment preferences for end-of-life care. Objective To examine patient-reported end-of-life values and needs of adolescents with cancer and congruence with their families' understanding of these needs. Design, Setting, and Participants This cross-sectional survey was conducted among adolescent-family dyads from July 16, 2016, to April 30, 2019, at 4 tertiary care pediatric US hospitals. Participants included 80 adolescent-family dyads (160 participants) within a larger study facilitating pediatric advance care planning. Adolescent eligibility criteria included being aged 14 to 21 years, English speaking, being diagnosed with cancer at any stage, and knowing their diagnosis. Family included legal guardians for minors or chosen surrogate decision-makers for those aged 18 years or older. Data analysis was performed from April 2019 to November 2019. Exposure Session 1 of the 3-session Family Centered Pediatric Advance Care Planning for Teens With Cancer intervention. Main Outcomes and Measures The main outcome was congruence between adolescents with cancer and their families regarding adolescents' values, goals, and beliefs about end-of-life care. Prevalence-adjusted and bias-adjusted κ (PABAK) values were used to measure congruence on the Lyon Advance Care Planning Survey-Revised (Patient and Surrogate versions). Results A total of 80 adolescent-family dyads (160 participants) were randomized to the intervention group in the original trial. Among the adolescents, 44 (55.0%) were female and 60 (75.0%) were white, with a mean (SD) age of 16.9 (1.8) years. Among family members, 66 (82.5%) were female and 65 (81.3%) were white, with a mean (SD) age of 45.3 (8.3) years. Family members' understanding of their adolescent's beliefs about the best time bring up end-of-life decisions was poor: 86% of adolescents wanted early timing (before getting sick, while healthy, when first diagnosed, when first sick from a life-threatening illness, or all of the above), but only 39% of families knew this (PABAK, 0.18). Families' understanding of what was important to their adolescents when dealing with their own dying was excellent for wanting honest answers from their physician (PABAK, 0.95) and understanding treatment choices (PABAK, 0.95) but poor for dying a natural death (PABAK, 0.18) and being off machines that extend life, if dying (PABAK, 0). Conclusions and Relevance Many families had a poor understanding of their adolescent's values regarding their own end-of-life care, such as when to initiate end-of-life conversations and preference for being off machines that extend life. Pediatric advance care planning could minimize these misunderstandings with the potential for a substantial impact on quality of care.
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Affiliation(s)
- Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center, Akron Children’s Hospital, Akron, Ohio
- Rebecca D. Considine Research Institute, Akron Children’s Hospital, Akron, Ohio
| | - Daniel H. Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Akron Children’s Hospital, Akron, Ohio
- Rebecca D. Considine Research Institute, Akron Children’s Hospital, Akron, Ohio
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care, St Jude Research Hospital, Memphis, Tennessee
| | - Jennifer Needle
- Center for Bioethics, Department of Pediatrics, University of Minnesota, Minneapolis
| | - Jessica D. Thompkins
- Center for Translational Research, Children’s Research Institute, Children’s National Hospital, Washington, DC
| | - Yao I. Cheng
- Division of Biostatistics and Study Methodology, Center for Translational Research, Children’s Research Institute, Children’s National Hospital, Washington, DC
| | - Jichuan Wang
- Division of Biostatistics and Study Methodology, Center for Translational Research, Children’s Research Institute, Children’s National Hospital, Washington, DC
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Maureen E. Lyon
- George Washington University School of Medicine and Health Sciences, Washington, DC
- Division of Adolescent and Young Adult Medicine, Center for Translational Research, Children’s Research Institute, Children’s National Hospital, Washington, DC
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12
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Abstract
The aim of deprescribing in end-of-life care is to improve the patient's quality of life by reducing their drug burden. It is essential to engage the patients and enable them to make choices about medications by discussing their preferences and implement a pharmacy management plan. Withdrawing medications during the end stages of life is extremely complex because the period of care varies substantially. The aim of this article is to address polypharmacy within end-of-life care. It will review which medications should be stopped by examining the non-essential and essential drugs. The intention is to encourage an approach to care which provides an equal balance between treatment and patient expectation.
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Affiliation(s)
- Emma Gardner
- Community Nurse Practitioner, Dorset HealthCare NHS, University NHS Foundation Trust Westminster Memorial Hospital, Dorset
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13
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Boss RD. Social Disparities and Death Among Children With Complex Chronic Conditions. Pediatrics 2019; 143:peds.2019-0511. [PMID: 30971432 DOI: 10.1542/peds.2019-0511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Renee D Boss
- Division of Neonatology, Department of Pediatrics, School of Medicine and Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland
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14
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Lyon ME, Squires L, D'Angelo LJ, Benator D, Scott RK, Greenberg IH, Tanjutco P, Turner MM, Weixel TE, Cheng YI, Wang J. FAmily-CEntered (FACE) Advance Care Planning Among African-American and Non-African-American Adults Living With HIV in Washington, DC: A Randomized Controlled Trial to Increase Documentation and Health Equity. J Pain Symptom Manage 2019; 57:607-616. [PMID: 30472318 PMCID: PMC6382515 DOI: 10.1016/j.jpainsymman.2018.11.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/09/2018] [Accepted: 11/14/2018] [Indexed: 12/25/2022]
Abstract
CONTEXT No prospective studies address disease-specific advance care planning (ACP) for adults living with HIV/AIDS. OBJECTIVE To examine the efficacy of FAmily-CEntered (FACE) ACP in increasing ACP and advance directive documentation in the medical record. METHODS Longitudinal, two-arm, randomized controlled trial with intent-to-treat design recruited from five hospital-based outpatient HIV clinics in Washington, DC. Adults living with HIV and their surrogate decision-makers (N = 233 dyads) were randomized to either an intensive facilitated two-session FACE ACP (Next Steps: Respecting Choices goals of care conversation and Five Wishes advance directive) or healthy living control (conversations about developmental/relationship history and nutrition). RESULTS Patients (n = 223) mean age: 51 years, 56% male, 86% African-American. One hundred ninety-nine dyads participated in the intervention. At baseline, only 13% of patients had an advance directive. Three months after intervention, this increased to 59% for the FACE ACP group versus 17% in the control group (P < 0.0001). Controlling for race, the odds of having an advance directive in the medical record in the FACE ACP group was approximately seven times greater than controls (adjusted odds ratio = 6.58, 95% CI: 3.21-13.51, P < 0.0001). Among African-Americans randomized to FACE, 58% had completed/documented advance directives versus 20% of controls (P < 0.0001). CONCLUSIONS The FACE ACP intervention significantly improved ACP completion and advance directive documentation in the medical record among both African-American and non-African-American adults living with HIV in Washington, DC, providing health equity in ACP, which can inform best practices.
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Affiliation(s)
- Maureen E Lyon
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA; George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Leah Squires
- Washington DC Veterans Affairs Medical Center, Washington, DC
| | - Lawrence J D'Angelo
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA; George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Debra Benator
- George Washington University School of Medicine and Health Sciences, Washington, DC; Washington DC Veterans Affairs Medical Center, Washington, DC
| | - Rachel K Scott
- MedStar: Health Research Institute and Washington Hospital Center; George Washington University Milken School of Public Health, Washington, DC, USA
| | - Isabella H Greenberg
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA
| | - Patricia Tanjutco
- MedStar: Health Research Institute and Washington Hospital Center; George Washington University Milken School of Public Health, Washington, DC, USA
| | | | - Tara E Weixel
- Office of the Clinical Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Yao I Cheng
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA
| | - Jichuan Wang
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA; George Washington University School of Medicine and Health Sciences, Washington, DC
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15
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Lyon ME, Garvie PA, D'Angelo LJ, Dallas RH, Briggs L, Flynn PM, Garcia A, Cheng YI, Wang J. Advance Care Planning and HIV Symptoms in Adolescence. Pediatrics 2018; 142:e20173869. [PMID: 30341154 PMCID: PMC6317555 DOI: 10.1542/peds.2017-3869] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To determine the effect of family-centered pediatric advance care planning (FACE pACP) on HIV-specific symptoms. METHODS In this single-blinded, randomized controlled trial conducted at 6 US hospital-based HIV clinics, 105 adolescent-family dyads, randomly assigned from July 2011 to June 2014, received 3 weekly sessions in either the FACE pACP arm ([1] pediatric advance care planning survey, [2] Respecting Choices interview, and [3] 5 Wishes directive) or the control arm ([1] developmental history, [2] safety tips, and [3] nutrition and exercise tips). The General Health Assessment for Children measured patient-reported HIV-specific symptoms. Latent class analyses clustered individual patients based on symptom patterns. Path analysis examined the mediating role of dyadic treatment congruence with respect to the intervention effect on symptom patterns. RESULTS Patients were a mean age of 17.8 years old, 54% male, and 93% African American. Latent class analysis identified 2 latent HIV-symptom classes at 12 months: higher symptoms and suffering (27%) and lower symptoms and suffering (73%). FACE pACP had a positive effect on dyadic treatment congruence (β = .65; 95% CI: 0.04 to 1.28), and higher treatment congruence had a negative effect on symptoms and suffering (β = -1.14; 95% CI: -2.55 to -0.24). Therefore, FACE pACP decreased the likelihood of symptoms and suffering through better dyadic treatment congruence (β = -.69; 95% CI: -2.14 to -0.006). Higher religiousness (β = 2.19; 95% CI: 0.22 to 4.70) predicted symptoms and suffering. CONCLUSIONS FACE pACP increased and maintained agreement about goals of care longitudinally, which lowered adolescents' physical symptoms and suffering, suggesting that early pACP is worthwhile.
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Affiliation(s)
- Maureen E Lyon
- Divisions of Adolescent and Young Adult Medicine and
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Patricia A Garvie
- Research Department, Children's Diagnostic and Treatment Center, Fort Lauderdale, Florida
| | - Lawrence J D'Angelo
- Divisions of Adolescent and Young Adult Medicine and
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Ronald H Dallas
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Linda Briggs
- Respecting Choices, Coalition to Transform Advanced Care Innovations, Washington, District of Columbia; and
| | - Patricia M Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ana Garcia
- Department of Pediatrics, Division of Infectious Disease and Immunology, Batchelor Children's Research Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Yao I Cheng
- Biostatistics and Study Methodology, Center for Translational Science, Children's Research Institute, Children's National, Washington, District of Columbia
| | - Jichuan Wang
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
- Biostatistics and Study Methodology, Center for Translational Science, Children's Research Institute, Children's National, Washington, District of Columbia
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16
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Abstract
This article describes the preparation, rationale, and benefits of talking with adolescents who have life-threatening or life-limiting illness about advance care planning (ACP) and end-of-life concerns in a developmentally sensitive manner. The first step is to ensure that a health care provider is ready to work with adolescents in ACP discussions by taking a self-inventory, learning communication skills, and understanding individual barriers. The authors then outline how to assess patient and family readiness, including developmental, cultural, personal, and psychosocial considerations. Evidence-based techniques for respectfully and productively engaging adolescents in ACP conversations are discussed.
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Affiliation(s)
- Maryland Pao
- National Institute of Mental Health, 10 Center Drive MSC 1276, NIH Building 10 CRC 6-5340, Bethesda, MD 20892-1276, USA.
| | - Margaret Rose Mahoney
- Office of the Clinical Director, National Institute of Mental Health, 10 Center Drive MSC 1276, NIH Building 10 CRC 6-5360, Bethesda, MD 20892-1276, USA
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