1
|
Turner H, Davis ES, Martinez I, Anshumani S, Boresino S, Buckingham S, Caudill C, Dai C, Mendoza E, Moynihan KM, Puttock LA, Tefera R, Bhatia S, Johnston EE. Racial Disparities in Palliative Care at End-of-life in Children with Advanced Heart Disease in the South. J Pediatr 2024:114284. [PMID: 39218206 DOI: 10.1016/j.jpeds.2024.114284] [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: 05/22/2024] [Revised: 08/05/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To examine specialty pediatric palliative care (SPPC) and end-of-life (EOL) care for children with advanced heart disease in Alabama, including rates of and disparities in SPPC involvement. STUDY DESIGN We performed a retrospective study from electronic health records of children (≤21 years at death) who died with advanced heart disease at a single institution between 2012 and 2019 (n=128). The main outcome was SPPC consult; we assessed clinical and sociodemographic factors associated with SPPC. RESULTS The median age at death was 6 months (IQR=1-25 months) with 80 (63%) ≤1 year; 46% were Black and 45% non-Hispanic White. Seventy (55%) children had critical congenital heart disease, 45 (35%) non-critical congenital heart disease, and 13 (10%) acquired heart disease. Twenty-nine children (22%) received SPPC. Children ≤1 year at time of death and Black children were less likely to receive SPPC (adjusted odds ratio [95% confidence interval]: 0.2 [0.1-0.6], reference >1 year; 0.2 [0.1-0.7], reference non-Hispanic White). SPPC was associated with death while receiving comfort-focused care (30.6 [4.5-210]), do not resuscitate orders (8.2 [2.1-31.3]), and hospice enrollment (no children without SPPC care were enrolled in hospice) but not medically intense EOL care (ICU admission, mechanical ventilation, hemodialysis, or CPR) or death outside the ICU. CONCLUSIONS Children dying with advanced heart disease in Alabama did not have routine SPPC involvement; infants and Black children had lower odds of SPPC. SPPC was associated with more comfort-focused care. Disparities in SPPC utilization for children with advanced heart disease need further examination.
Collapse
Affiliation(s)
- Harrison Turner
- University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, Alabama
| | | | - Isaac Martinez
- Institute for Cancer Outcomes and Survivorship, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shambihavi Anshumani
- University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, Alabama
| | - Santiago Boresino
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Susan Buckingham
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama
| | - Caroline Caudill
- Department of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chen Dai
- Institute for Cancer Outcomes and Survivorship, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Erika Mendoza
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lucas A Puttock
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama; Palliative Care Service, Department of Medicine, University of California Irving, Orange, California
| | - Raba Tefera
- Department of Surgery, Boston University, Boston, MA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, Heersink 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, Heersink 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.
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Mejia EJ, Xiao R, Walter JK, Feudtner C, Lin KY, DeWitt AG, Prasad Kerlin M. Programmatic Palliative Care Consultations in Pediatric Heart Transplant Evaluations. Pediatr Cardiol 2024; 45:1064-1071. [PMID: 38453700 PMCID: PMC11056287 DOI: 10.1007/s00246-024-03422-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024]
Abstract
Guidelines advocate for integrating palliative care into the management of heart failure (HF) and of children with life-limiting disease. The potential impact of palliative care integration into pediatric HF on patient-centered outcomes is poorly understood. The present study sought to assess the association of programmatic implementation of palliative care into the heart transplant evaluation process with hospital-free days (HFD) and end of life (EOL) treatment choices. The study included patients less than 19 years of age who underwent a heart transplant evaluation between February 2012 and April 2020 at a single center. Patients evaluated in the programmatic palliative care (PPC) era (January 2016-April 2020) were compared to patients evaluated in the pre-PPC era (February 2012-December 2015). The study included 188 patients, with 91 (48%) in the PPC era and 97 (52%) in the pre-PCC era. Children < 1 year of age at the time of the evaluation represented 32% of the cohort. 52% of patients had single ventricle physiology. PPC was not significantly associated with increased HFD (IRR 0.94 [95% CI 0.79-1.2]). PPC was however associated with intensity of EOL care with decreased mechanical ventilation (OR 0.12 [95% CI 0.02-0.789], p = 0.03) and decreased use of ionotropic support (OR 0.13 [95% CI 0.02-0.85], p =0.03). PPC in pediatric heart transplant evaluations may be associated with less invasive interventions at EOL.
Collapse
Affiliation(s)
- Erika J Mejia
- Divisions of Cardiology and Palliative Care, Ann & Robert Lurie Children's Hospital, Chicago, IL, USA.
| | - Rui Xiao
- Division of Biostatistics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer K Walter
- Division of General Pediatrics and the Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Chris Feudtner
- Division of General Pediatrics and the Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kimberly Y Lin
- Division of Cardiology, Children's Hospital Of Philadelphia, PA, Philadelphia, USA
| | - Aaron G DeWitt
- Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Meeta Prasad Kerlin
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
4
|
Walter J, Hill DL, Cetin A, DeWitt A, Kellom K, Quarshie W, Griffis H, Shults J, Arnold R, Tjia J, Puopolo K, Curley MAQ, Feudtner C. A Pediatric Interprofessional Cardiac Intensive Care Unit Intervention: CICU Teams and Loved Ones Communicating (CICU TALC) is Feasible, Acceptable, and Improves Clinician Communication Behaviors in Family Meetings. Pediatr Cardiol 2024:10.1007/s00246-024-03497-7. [PMID: 38700711 DOI: 10.1007/s00246-024-03497-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/11/2024] [Indexed: 07/17/2024]
Abstract
Parents of children in the pediatric cardiac intensive care unit (CICU) are often unprepared for family meetings (FM). Clinicians often do not follow best practices for communicating with families, adding to distress. An interprofessional team intervention for FM is feasible, acceptable, and positively impacts family preparation and conduct of FM in the CICU. We implemented a family- and team-support intervention for conducting FM and conducted a pretest-posttest study with parents of patients selected for a FM and clinicians. We measured feasibility, fidelity to intervention protocol, and parent acceptability via questionnaire and semi-structured interviews. Clinician behavior in meetings was assessed through semantic content analyses of meeting transcripts tracking elicitation of parental concerns, questions asked of parents, and responses to parental empathic opportunities. Logistic and ordinal logistic regression assessed intervention impact on clinician communication behaviors in meetings comparing pre- and post-intervention data. Sixty parents (95% of approached) were enrolled, with collection of 97% FM and 98% questionnaire data. We accomplished > 85% fidelity to intervention protocol. Most parents (80%) said the preparation worksheet had the right amount of information and felt positive about families receiving this worksheet. Clinicians were more likely to elicit parental concerns (adjusted odds ratio = 3.42; 95%CI [1.13, 11.0]) in post-intervention FM. There were no significant differences in remaining measures. Implementing an interprofessional team intervention to improve family preparation and conduct of FM is locally feasible, acceptable, and changes clinician behaviors. Future research should assess broader impact of training on clinicians, patients, and families.
Collapse
Affiliation(s)
- Jennifer Walter
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Justin Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Douglas L Hill
- Justin Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arzu Cetin
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aaron DeWitt
- Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Katie Kellom
- Policy Lab, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Qualitative Research Core, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William Quarshie
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Arnold
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Karen Puopolo
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Martha A Q Curley
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
| | - Chris Feudtner
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Justin Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
5
|
Nield LE, Dahan M, Guerra V, Mustafa S, Okun N, Freud L, Han RK, Kirsch R. Fetal Cardiology Bioethics: An Innovative New Curriculum for Cardiology Trainees. Pediatr Cardiol 2024; 45:703-709. [PMID: 38386036 DOI: 10.1007/s00246-024-03431-x] [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: 11/24/2023] [Accepted: 01/25/2024] [Indexed: 02/23/2024]
Abstract
Decision-making in fetal cardiology is fraught with ethical issues yet education in bioethics for trainees is limited or nonexistent. In this innovation report, we describe the development of a fetal cardiology bioethics curriculum designed to address this gap. The curriculum was developed to supplement the core curriculum for cardiology fellows and fetal cardiology subspecialty trainees. The series combines didactic and interactive teaching modalities and contains 5 key components: (1) introduction to bioethics and its role in fetal cardiology, (2) counseling and pathways for compassionate terminal care, (3) case vignette-based ethical analysis and discussion cases, (4) fetal counseling considerations for shared decision-making and recommendations, (5) facilitated communications role play. The curriculum was refined using session evaluations from end users. This report describes the innovative curriculum as a starting point for further incorporation and study of bioethical education in pediatric cardiology and fetal training programs.
Collapse
Affiliation(s)
- Lynne E Nield
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Maya Dahan
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Vitor Guerra
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Sonila Mustafa
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Nanette Okun
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Lindsay Freud
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Ra K Han
- St. Michael's Hospital, Toronto, Canada
| | - Roxanne Kirsch
- Department of Pediatrics, University of Toronto, Toronto, Canada.
- Division Cardiac Critical Care, Department of Critical Care, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Dept Critical Care, Toronto, ON, M5G 1X8, Canada.
- Department of Bioethics, The Hospital for Sick Children, Toronto, Canada.
| |
Collapse
|
6
|
Landzberg MJ. Palliative Care in Adult Congenital Heart Disease-Associated Advanced Heart Disease. Heart Fail Clin 2024; 20:237-243. [PMID: 38462327 DOI: 10.1016/j.hfc.2023.12.005] [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: 03/12/2024]
Abstract
The practice of palliative care (PC) strives to mitigate patient suffering through aligning patient priorities and values with care planning and via improved understanding of complex physical, psychosocial, and spiritual stressors and dynamics that contribute to patient-centered outcomes. Through representative 'case examples' and supportive data, the role and value of a PC consultant, within the framework of a comprehensive adult congenital heart disease (ACHD) team caring for ACHD with advanced heart disease, are reviewed.
Collapse
Affiliation(s)
- Michael J Landzberg
- Boston Adult Congenital Heart (BACH) Group, Heart Pal Team; Department of Cardiology, Brigham and Women's Hospital, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute.
| |
Collapse
|
7
|
McClung JA, Frishman WH, Aronow WS. The Role of Palliative Care in Cardiovascular Disease. Cardiol Rev 2024:00045415-990000000-00182. [PMID: 38169299 DOI: 10.1097/crd.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The American Heart Association has recommended that palliative care be integrated into the care of all patients with advanced cardiac illnesses. Notwithstanding, the number of patients receiving specialist palliative intervention worldwide remains extremely small. This review examines the nature of palliative care and what is known about its delivery to patients with cardiac illness. Most of the published literature on the subject concern advanced heart failure; however, some data also exist regarding patients with heart transplantation, pulmonary hypertension, valvular disease, congenital heart disease, indwelling devices, mechanical circulatory support, and advanced coronary disease. In addition, outcome data, certification requirements, workforce challenges, barriers to implementation, and a potential caveat about palliative care will also be examined. Further work is required regarding appropriate means of implementation, quality control, and timing of intervention.
Collapse
Affiliation(s)
- John Arthur McClung
- From the Departments of Cardiology and Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | | | | |
Collapse
|
8
|
Godfrey S, Kirkpatrick JN, Kramer DB, Sulistio MS. Expanding the Paradigm for Cardiovascular Palliative Care. Circulation 2023; 148:1039-1052. [PMID: 37747951 PMCID: PMC10539017 DOI: 10.1161/circulationaha.123.063193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 07/13/2023] [Indexed: 09/27/2023]
Abstract
Cardiovascular disease (CVD) is the leading cause of death worldwide. Despite medical advances, patients with CVD experience high morbidity and mortality rates, affecting their quality of life and death. Among CVD conditions, palliative care has been studied mostly in patients with heart failure, where palliative care interventions have been associated with improvements in patient-centered outcomes, including quality of life, end-of-life care, and health care use. Although palliative care is now incorporated into the American Heart Association/American College of Cardiology/Heart Failure Society of America guidelines for heart failure, the role of palliative care for non-heart failure CVD remains uncertain. Across all causes of CVD, palliative care can play an important role in all domains of CVD care from initial diagnosis to terminal care. In addition to general cardiovascular palliative care practices applicable to all areas, disease-specific palliative care needs may warrant individualized palliative care models. In this review, we discuss the role of cardiovascular palliative care for ischemic heart disease, valvular disease, arrhythmias, peripheral artery disease, and adult congenital heart disease. Although there are multiple barriers to cardiovascular palliative care, we recommend a framework for studying and developing cardiovascular palliative care models to improve patient-centered goal-concordant care for this underserved patient population.
Collapse
Affiliation(s)
- Sarah Godfrey
- University of Texas Southwestern Medical Center, Division of Cardiology, Dallas, TX, USA
| | | | - Daniel B. Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Melanie S. Sulistio
- University of Texas Southwestern Medical Center, Division of Cardiology, Dallas, TX, USA
| |
Collapse
|
9
|
Haxel CS, Belser AH, DeSarno M, Glickstein J, Flyer JN. Pediatric Cardiology Condolence Letter Writing: Does a Fellowship Curriculum Impact Practice? J Pain Symptom Manage 2023; 66:e343-e352. [PMID: 37327916 DOI: 10.1016/j.jpainsymman.2023.06.001] [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: 05/25/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023]
Abstract
CONTEXT Condolence letter (CL) writing after the death of a child is an important opportunity for humanism. Pediatric cardiology fellowship training now recognizes the importance of palliative care, but rarely includes CL education, despite its fragile patient population. OBJECTIVES To address this professionalism gap, a formal CL writing curriculum was created and implemented in a pediatric cardiology fellowship. This study investigated the impact of the curriculum on pediatric cardiology CL writing, and broader CL practices and beliefs. METHODS Pediatric cardiology fellows at a high volume urban academic program from 2000 to 2022 were divided into two cohorts (exposure to CL curriculum [2014-2022] vs. no exposure [2000-2013]) and responded by anonymous electronic multiple choice and open ended survey to assess the CL curriculum and describe current CL practices and beliefs. Impact of curriculum elements was determined by ordinal ranking. A 5-point Likert scale was used to report physician behaviors. Chi-square tests of independence were utilized for group comparisons. RESULTS The overall survey response rate was 59% (63/107). Cardiologists who participated in the curriculum (64%, 35/55) were more likely to report writing CLs (80% vs. 40%; P < 0.01). Impactful curriculum elements included the opportunity for all fellows to contribute to a CL (78%) and identifying a primary fellow to write the CL (66%). A majority (>75%) of curriculum participants agreed that formal teaching increased their frequency, ability, and comfort in writing CLs. CONCLUSION Development of condolence expression educational programs in pediatric cardiology training should be expanded.
Collapse
Affiliation(s)
- Caitlin S Haxel
- Department of Pediatric (C.S.H, J.N.F.), The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT; Division of Pediatric Cardiology (C.S.H.), University of Vermont Children's Hospital, Burlington, VT, USA.
| | - Abigail H Belser
- Boston Combined Residency Program (A.H.B.), Boston Children's Hospital, Boston, MA, USA
| | - Michael DeSarno
- Department of Medical Biostatistics (M.D.), The Robert Larner M.D. College of Medicine at the University of Vermont, Colchester, VT, USA
| | - Julie Glickstein
- Department of Pediatrics, Division of Pediatric Cardiology (J.G.), Morgan Stanley Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Jonathan N Flyer
- Department of Pediatric (C.S.H, J.N.F.), The Robert Larner M.D. College of Medicine at the University of Vermont, Burlington, VT; Division of Pediatric Cardiology (C.S.H.), University of Vermont Children's Hospital, Burlington, VT, USA
| |
Collapse
|
10
|
Everitt MD. End-stage care for children after heart transplant. FRONTIERS IN TRANSPLANTATION 2023; 2:1221166. [PMID: 38993880 PMCID: PMC11235272 DOI: 10.3389/frtra.2023.1221166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/12/2023] [Indexed: 07/13/2024]
Abstract
Heart transplant is performed annually in over 600 children worldwide to treat life-limiting cardiac disease. Conversations regarding waitlist mortality, post-transplant morbidity and mortality, and goals of care are commonplace pre-transplant. However, there is a void of information and resources for providers and families when end-stage disease recurs in the long-term transplant recipient. The purpose of this review is to discuss the care of the pediatric heart transplant recipient with chronic cardiac dysfunction occurring years after a successful transplant. This includes a need for transplant providers to have education and training related both to palliative care and medical ethics to improve shared decision making with patients and families.
Collapse
Affiliation(s)
- Melanie D. Everitt
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, CO, United States
| |
Collapse
|
11
|
Cousino MK, Miller VA, Smith C, Lim HM, Yu S, Lowery R, Uzark K, Fredericks EM, Wolfe J, Blume ED, Schumacher KR. Medical and End-of-Life Decision-Making Preferences in Adolescents and Young Adults with Advanced Heart Disease and Their Parents. JAMA Netw Open 2023; 6:e2311957. [PMID: 37145598 PMCID: PMC10163392 DOI: 10.1001/jamanetworkopen.2023.11957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/23/2023] [Indexed: 05/06/2023] Open
Abstract
Importance Despite high disease morbidity and mortality and complex treatment decisions, little is known about the medical and end-of-life decision-making preferences of adolescents and young adults (AYA) with advanced heart disease. AYA decision-making involvement is associated with important outcomes in other chronic illness groups. Objective To characterize decision-making preferences of AYAs with advanced heart disease and their parents and determine factors associated with these preferences. Design, Setting, and Participants Cross-sectional survey between July 2018 and April 2021 at a single-center heart failure/transplant service at a Midwestern US children's hospital. Participants were AYAs aged 12 to 24 years with heart failure, listed for heart transplantation, or posttransplant with life-limiting complications and a parent/caregiver. Data were analyzed from May 2021 to June 2022. Main Outcomes and Measures Single-item measure of medical decision-making preferences, MyCHATT, and Lyon Family-Centered Advance Care Planning Survey. Results Fifty-six of 63 eligible patients enrolled in the study (88.9%) with 53 AYA-parent dyads. Median (IQR) patient age was 17.8 (15.8-19.0) years; 34 (64.2%) patients were male, and 40 patients (75.5%) identified as White and 13 patients (24.5%) identified as members of a racial or ethnic minority group or multiracial. The greatest proportion of AYA participants (24 of 53 participants [45.3%]) indicated a preference for active, patient-led decision-making specific to heart disease management, while the greatest proportion of parents (18 of 51 participants [35.3%]) preferred they and physician(s) make shared medical decisions on behalf of their AYA, representing AYA-parent decision-making discordance (χ2 = 11.7; P = .01). Most AYA participants stated a preference to discuss adverse effects or risks of treatment (46 of 53 participants [86.8%]), procedural and/or surgical details (45 of 53 participants [84.9%]), impact of condition on daily activities (48 of 53 participants [90.6%]), and their prognosis (42 of 53 participants [79.2%]). More than half of AYAs preferred to be involved in end-of-life decisions if very ill (30 of 53 participants [56.6%]). Longer time since cardiac diagnosis (r = 0.32; P = .02) and worse functional status (mean [SD] 4.3 [1.4] in New York Heart Association class III or IV vs 2.8 [1.8] in New York Heart Association class I or II; t-value = 2.7; P = .01) were associated with a preference for more active, patient-led decision-making. Conclusions and Relevance In this survey study, most AYAs with advanced heart disease favored active roles in medical decision-making. Interventions and educational efforts targeting clinicians, AYAs with heart disease, and their caregivers are needed to ensure they are meeting the decision-making and communication preferences of this patient population with complex disease and treatment courses.
Collapse
Affiliation(s)
- Melissa K. Cousino
- Department of Pediatrics, Michigan Medicine, Ann Arbor
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor
| | - Victoria A. Miller
- Division of Adolescent Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia Smith
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Heang M. Lim
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Sunkyung Yu
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Ray Lowery
- Department of Pediatrics, Michigan Medicine, Ann Arbor
| | - Karen Uzark
- Department of Pediatrics, Michigan Medicine, Ann Arbor
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor
| | | | - Joanne Wolfe
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Elizabeth D. Blume
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | | |
Collapse
|
12
|
Tadros HJ, Gupta D. "A Good Death": Role of Shared Decision Making and Palliative Care in Children with Cardiac Disease. Pediatr Cardiol 2023; 44:958-959. [PMID: 36773076 DOI: 10.1007/s00246-023-03124-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023]
Affiliation(s)
- Hanna J Tadros
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Dipankar Gupta
- Congenital Heart Center, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, USA.
| |
Collapse
|