Respiratory symptoms in children dying from malignant disease

Palliation of Dyspnea in pediatrics

Dyspnea is a complex physiologic and psychosocial symptom that is difficult to characterize and measure, but essential to treat, as it has a significant effect on quality of life. Although palliation of dyspnea in the child with chronic illness is an under-researched area, children and their families cannot wait for the research to catch up with their current needs. This article addresses several aspects of dyspnea in pediatrics palliative care, with an eye toward practical suggestions for evaluation and management.

Symptoms in children/young people with progressive malignant disease: United Kingdom Children's Cancer Study Group/Paediatric Oncology Nurses Forum survey

AIM

The purpose of this study was to survey symptoms in children/young people with progressive cancer and identify which are the most important and which are the most difficult to treat effectively.

PATIENTS AND METHODS

This was a questionnaire survey of 22 United Kingdom Children's Cancer Study Group centers. Data were collected by clinical nurse specialists in pediatric oncology regarding children/young people between 0 and 20 years of age, using 2 questionnaires. The first collected demographic details and the second data about the occurrence and perceived impact of symptoms.

RESULTS

There were 185 children/young people from 20 centers registered in the study, aged 4 months to 19 years (mean: 8.7 years), who received palliative care for a median of 34 days (range: 0-354 days). Data were analyzed for 164 children/young people who died during the study. Between referral to palliative care and death, there were significant increases in the number of symptoms reported and children/young people experiencing pain (70.6% vs 91.5%). Symptoms included some that often go unrecognized in children/young people, for example, anorexia, weight loss, and weakness. The nature of the underlying malignancy significantly influenced the prevalence of some symptoms. There were significant differences between the symptoms associated with central nervous system tumors and other groups. Pain other than headache occurred more commonly in children with solid tumors (98.4%) than in others (87%). Neurologic symptoms, including headache, were universal among those with central nervous system tumors.

CONCLUSION

This study documents the frequency of symptoms and contrasts the experiences of children/young people with different groups of malignant disease. With access to skilled symptom control, pain can be effectively treated in most children/young people. Some other symptoms often remain intractable. The study highlights the need for further research to establish the effectiveness of therapeutic interventions for symptom control and their impact on the quality of life for children/young people dying from cancer.

Issues and challenges in palliative care for children with cancer

Although the majority of children with cancer are cured of their illness, the children who die from their disease or complications require special care at the end of life. We present special issues and challenges unique to pediatric palliative care and suggest ways in which we can face these issues and address the challenges. The care must be family centered and balance the needs of the health-care system, the child, and the family. The way in which the care is delivered, the services provided, and the place in which that care is given are not carved into a simple protocol. Quality of life is an important concept that is often overlooked. Educational initiatives for patients, families, health-care providers, and third-party payers are essential. Reimbursement for palliative care services presents a large barrier to provision of appropriate services to all children and families in need. Hypothesis-driven research must be developed to help us learn more about how best to deliver end-of-life care to children and their families.

Issues and challenges in palliative care for children with cancer

Although the majority of children with cancer are cured of their illness, the children who die from their disease or complications require special care at the end of life. We present special issues and challenges unique to pediatric palliative care and suggest ways in which we can face these issues and address the challenges. The care must be family centered and balance the needs of the health-care system, the child, and the family. The way in which the care is delivered, the services provided, and the place in which that care is given are not carved into a simple protocol. Quality of life is an important concept that is often overlooked. Educational initiatives for patients, families, health-care providers, and third-party payers are essential. Reimbursement for palliative care services presents a large barrier to provision of appropriate services to all children and families in need. Hypothesis-driven research must be developed to help us learn more about how best to deliver end-of-life care to children and their families.

[Treatment of non-painful symptoms in terminally ill children]

The care of children at the end of life is gradually improving. Nevertheless, more than half suffer from intractable symptoms before dying. Although pain has been the subject of clinical research, evidence-based data are almost completely lacking for other symptoms, highlighting the need for clinical research in palliative care. We review the available evidence on fatigue, anorexia, dyspnea, respiratory secretions, cough, constipation, mouth dryness, urinary obstruction, terminal convulsions and gasping. When evidence is lacking, we offer our empiric approach. Short duration benzodiazepines have become an important component of treatment that should remain simple, while providing the dying child the comfort needed to experience the highest quality relationships with those around him.

Caring for children with advanced cancer integrating palliative care

The care of children with advanced cancer is multifaceted. Treatment should focus on continued efforts to control the underlying illness whenever possible. At the same time, children and their families should have access to interdisciplinary care aimed at promoting optimal physical, psychological and spiritual wellbeing. Open and compassionate communication can best facilitate meeting the goals of these children and families. However, there remain significant barriers to achieving optimal care related to lack of formal education, reimbursement issues and the emotional impact of caring for a dying child. Future research efforts should focus on ways to enhance communication, symptom management and quality of life for children with advanced cancer and their families. As efforts to break down barriers and create the evidence base continue, we conclude as follows: this is a most rewarding part of the practice of medicine. A kind word and caring attitude are remembered for decades.

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.

Dyspnea: assessment and treatment

Dyspnea, or breathlessness, is a very distressing and prevalent symptom for patients with terminal cancer. Assessment for this symptom is generally poorly conducted, and it is therefore frequently underdiagnosed and inadequately treated. This paper outlines several tools found in the literature that may be beneficial to us in assessing this symptom. There will also be a full report on the application of these scales as used in a hospital audit of all in-patients at the Queensway- Carleton Hospital in Nepean, Ontario, during the month of June 1995. Results of this hospital audit revealed that 33% of all patients in hospital complained of some degree of breathlessness on both the Linear Analogue Scale Assessment and the Borg Scale. However, when the Modified Medical Research Council Dyspnea Scale and the Oxygen Cost Diagram Scale were used 75.6% and 78.5% respectively now complained of significant shortness of breath interfering with their quality of life. We also found that patients experiencing dyspnea were 39% more likely to complain of other symptoms than patients with no shortness of breath and were 55% more likely to report other symptoms as being severe. A short section will also outline the medical and nursing management of dyspnea and will include a discussion of possibly correcting the cause of breathlessness, environmental issues, and pharmacological management of dyspnea. It is advocated that during the terminal stages of a patient's illness, when assessment tools are no longer feasible or possible, that a "breathing comfortably" approach be adopted for patient and family comfort.

Facilitating the care of terminally Ill children

Life-threatening illness is fortunately rare in children. Some children, however, will need palliative care for symptom control; psychological support may be needed by the child and the child's family; and families may require help with decisions about life-prolonging treatment. Providing consistent high-quality care for a relatively uncommon problem is difficult. Adult palliative care services, liaison with pediatricians can help provide this care.