The incidence of requests for a quicker terminal course

Designing and implementing a longitudinal study of children with neurological, genetic or metabolic conditions: charting the territory

Background

Children with progressive metabolic, neurological, or chromosomal conditions and their families anticipate an unknown lifespan, endure unstable and often painful symptoms, and cope with erratic emotional and spiritual crises as the condition progresses along an uncertain trajectory towards death. Much is known about the genetics and pathophysiology of these diseases, but very little has been documented about the trajectory of symptoms for children with these conditions or the associated experience of their families. A longitudinal study design will help to close this gap in knowledge.

Methods/Design

Charting the Territory is a longitudinal descriptive, correlational study currently underway with children 0-19 years who are diagnosed with progressive neurological, metabolic, or chromosomal conditions and their families. The purpose of the study is to determine and document the clinical progression of the condition and the associated bio-psychosocial-spiritual experiences of the parents and siblings age 7-18 years. Approximately 300 families, both newly diagnosed children and those with established conditions, are being recruited in six Canadian cities. Children and their families are being followed for a minimum of 18 months, depending on when they enroll in the study. Family data collection will continue after the child's death if the child dies during the study period. Data collection includes monthly parental assessment of the child's symptoms; an annual functional assessment of the child; and completion of established instruments every 6 months by parents to assess family functioning, marital satisfaction, health status, anxiety, depression, stress, burden, grief, spirituality, and growth, and by siblings to assess coping and health. Impact of participation on parents is assessed after 1 year and at the end of the study. Chart reviews are conducted at enrollment and at the conclusion of the study or at the time of the child's death.

Discussion

Knowledge developed from this study will provide some of the first-ever detailed descriptions of the clinical symptom trajectory of these non-curable progressive conditions and the bio-psychosocial-spiritual aspects for families, from diagnosis through bereavement. Information about developing and implementing this study may be useful to other researchers who are interested in designing a longitudinal study.

The demand for euthanasia in palliative care units: a prospective study in seven units of the 'Rhône-Alpes' region

A prospective survey of five palliative care units in the Rhône-Alpes region of France over a six-month period identified 13 requests for euthanasia (from the patient, family or both). The frequency of the request was low at 2.1% (of 611 patients). We have sought to establish the reasons for this request from the patient or family and the follow up of this request over time.

The expression of pain in infants with developmental delays

OBJECTIVE

To explore how infants with developmental delays express pain, we analysed facial expressions of infants receiving their routine immunization at around 4-6 months developmental age. The sample included eight infants with developmental disabilities (mean developmental age 4.8 months) and 30 typically developing infants (mean age 4 months). The Maximally Discriminative Facial Movement Coding system was used to code infant facial expressions during immunization.

RESULTS

The pain expression was by far the most common of all facial expressions following immunization for both groups of infants. Those with disabilities produced significantly fewer discrete high-intensity expressions of pain, and significantly more blended expressions than typically developing infants. Expressions of fear, sadness and anger were relatively infrequent in both groups. Infants with disabilities used their upper face less often than typically developing infants, and their mid face was uncodeable more often.

CONCLUSION

Infants with developmental delays were likely to show pain in facial expressions less clearly than typically developing infants. It is important for health care professionals to be aware that this may be the case when considering the administration of analgesia for such children.

Dealing with uncertainty: parental assessment of pain in their children with profound special needs

BACKGROUND

Despite advances in the assessment and management of children's pain, children with profound special needs are especially vulnerable to poor pain management. Their underpinning condition often severely compromises their ability to express pain through the usual verbal and behavioural routes. The lack of any appropriate framework for assessment results in a suboptimum and inaccurate approach to an important aspect of their care.

PURPOSE

The purpose of the study was to explore the ways in which parents of children with profound special needs assess and manage their children's pain.

METHODS

Qualitative case study design underpinned the study using guided interviews with the 15 parents/carers (of 12 children aged 5-16 years with profound special needs).

ETHICAL APPROVAL

Ethics Committee approval was gained.

FINDINGS

A number of themes emerged from the data including learning to live with pain, dealing with uncertainty, expression of pain and making decisions.

CONCLUSIONS

Parents felt that their child had learned to live with significant levels of chronic and acute pain. Assessment of pain was an uncertain and complex process requiring parents to draw on skills and knowledge developed over a number of years. Parents used different strategies for both the assessment and management of pain based on an intimate knowledge of their child's usual nonpain state. Even with a limited repertoire of behaviours available to them, children were able to express pain. Parents often felt isolated in relation to pain management and under-used as a resource by health professionals.

Nurses' attitudes to palliative care in nursing homes in Western Australia

Nursing homes are one of the care settings in Western Australia where older people may spend their final years. Residents should be able to receive palliative care where appropriate, but this type of care is not always available at some nursing homes in the state. This study investigated nurses' attitudes to palliative care in nursing homes by examining their cognitive, affective and behavioural information. A sample of 228 nurses working in nursing homes completed a questionnaire, using a free response methodology. Results showed that participants had either a positive or negative attitude to palliative care. Cognitive and affective information significantly and independently predicted the attitudes of nurse, whereas knowledge of palliative care did not contribute significantly to these attitudes. Nurses currently working in palliative care were more positively disposed towards such care, but this disappeared when they ceased working in the area. There is an emphasis on education in the literature which does not take into account the beliefs and emotions of the nurse. Therefore, there is a need to consider these in undergraduate and postgraduate training for nurses. Current experience is also important in palliative care education. The results obtained from nurses in this study should be incorporated into policy for introducing palliative care into nursing homes and used to provide support and assistance to nurses working in this field.

Paediatric palliative care: a lack of research-based evidence

Providing the best possible care for the child and family is paramount to health professionals working in paediatric palliative care. However, there is little research which enables practitioners to question their current practice. There are concerns about conducting research on children receiving palliative care at such a sensitive time for the child and his/her family. These concerns must be considered against the growing demand for clear standards and guidelines for practice within health care. According to the Department of Health (DoH) there is no place within the modern healthcare system for the adoption of unproven theories or outdated care (DoH, 1998). While no-one would question the dedication and care being delivered to children and their families by well-trained staff, the lack of research is a cause for concern. A group of students undertaking a degree module in paediatric palliative care identified the lack of literature and research in this area and have undertaken a review of the available literature.